arterial line,central line,CVPby dr deepak nirwal kalyani hospital


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Arterial line ,arterial BP ,central line, CVP kalyani hospital kiratpur bijnor up


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NIBP , ABP , CVP Presented By:-Dr Deepak Nirwal Moderator :- Dr R. Subhedar sir & Dr. A. Patil sir Dept . Of Anaesthesia SBH GMC , Dhule


INTRODUCTION Frequent BP monitoring:- Component of min mandatory monitoring Drug Titration Fluid Management Impending danger to patient SAFETY OF PATIENT I C U IC C U P I C U S I C U H D U O P D POSTOP O T

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Korotkoff - sounds:

Korotkoff - sounds I- clear tapping sound II- softer & longer III- crisper & louder IV- muffled & softer V- disappear



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OSCILLOMETRY Operating principle - NIBP

Operating Principles:

Operating Principles Microprocessor controls the sequence of inflation and deflation of the cuff. During 1 st cycle of NIBP, cuff is inflated to a predetermined pressure , that is held constant while monitor tries to detect oscillation , if significant oscillation still present , then cuff is inflated further , most NIBP monitor stop in first cycle turn at 160 mmHg. If initial cuff pressure is greater then necessary to determine SBP , then monitor may decrease this pressure for next cycle or vice versa A transducer senses the pressure changes, which are processed by the microprocessor. The mean arterial pressure (MAP) corresponds to the maximum oscillation at the lowest cuff pressure. SBP & DBP are then calculated from an empirically derived algorithm (inbuilt software vary from manufacture to manufacture ) .

Operating Principles :

Diastolic pressure corresponds to the onset of rapidly decreasing oscillations. It is also calculated from the systolic and, MAP. (MAP= diastolic + one-third pulse pressure) = {2DBP + SBP } / 3 Operating Principles

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Operating Principle


STANDARDS AMERICAN STANDARDS -2002 : BP determined by the device be equivalent to those obtained by intra-arterial technique by trained person. INTERNATIONAL STANDARDS -1999 : Equipment specified for adults 300 mm Hg Equipment specified for neonates 150 mmHg

Sources of error :

Sources of error If the cuff is too small, the blood pressure over-reads. Similarly, if too large then the blood pressure under-reads (greatest error is seen with an undersized cuff). Pressure tubing compress / kink . Shivering – high SBP External pressure on the cuff (e.g. the surgeon!) can cause inaccuracies. Arm position not proper .



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cuff size Upper Arm Circumference Cuff Name Bladder Width (cm) 5 – 7.5 7.5 – 13 13 –20 20 – 32 32 –42 42 – 50 Newborn Infant Child Adult Wide/large adult Thigh 3 5 8 13 17 20 Cuff and arm relationship Too small cuff – overestimate Too large - underestimate Cuff width – 40-50 % circumference , 125-150% of diameter Circumference measure at mid point of limb Cuff length has little effect as long as the bladder encircles atleast 50% of circumference .

Site of cuff placement :

Site of cuff placement Site can be wrist , forearm , midarm , thigh , ankle As the site moves more peripherally , the SBP increases and DBP decreases . Increase in vascular tone may result in an increase in pulse pressure . But vascular disease / peripheral vasoconstriction may cause reduced pressure at distal location . MAP and DBP at ankle are comparable with those measured in the arm , but SBP is higher .

Arm Position :

Arm Position Heart and cuff must be at same level , if not than do correction . For each 10 cm → 7.5 mmHg Height above than add. Height below than subtract .

Complications :

Complications Damage to Underlying Tissues : Petechiae, erythema, edema, thrombophlebitis, skin avulsion- predisposing with drugs like Neuropathies : Median Ulnar, Radial nerves – resolves spontaneously predisposing – excessive movements Mechanical Problems : failure or NIBP readings may cause serious problems—leaking cuff, hose, connectors Artifacts : intrinsic , extrinsic motion artifacts Air Embolism : Line used to inflate the cuff is connected to an intravenous line, a serious air embolus can result.

Advantages :

Advantages Automaticity Simplicity Reliability Non invasiveness Usefulness Versatility Monitor integrity

Disadvantages :

Disadvantages Unsuitable situations Patient discomfort Non continuous measurements Clinical Limitations



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Vasotrac :


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Wrist Module Connecting cable Monitor / Display Pressure sensing mechanism applies variable pressures pressure - counter pressure method Wave form analysis gives SP DP MAP. Range 40 to 240 Accurate with arrhythmias even V A S O T R A C

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Vasotrac does not provide continuous BP measurement, it provides readings 3 to 4 times per minute than the Intermittent method.

T-line Tensymeter:

T-line Tensymeter

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Utilizes arterial Tonometry. Peripheral artery is slightly compressed pulse wave is picked up by the transducer placed over it. Thee components 1.disposable wrist splint 2.disposable radial artery sensor 3.reusable bracelet. T- LINE TENSYMETER

PowerPoint Presentation:

First wrist restraint is applied Sensor is aligned to pulsation, then bracelet is applied. The pulsations are converted to waveform This provides continuous beat to beat NIBP measurements The B P closely agreed with measurements done via Invasive methods on opposite pulse. T- LINE TENSYMETER

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PLETHYSMOGRAPHY Light emitting diode – photoelectric cell Detects changes in finger volume Solenoid controlled air pump rapidly modulates cuff pressures which are displayed as beat to beat tracings. Although the pressures are intra-arterial determinations, Plethysmography has proved unreliable in patients with poor peripheral perfusion, hypothermia, therefore not recommended for routine clinical use.

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DOPPLER PROBE DOPPLER’S EFFECT is shift in the frequency of sound waves when their source moves relative to the observer. As RBC moves in artery Doppler frequency shift will be detected by the probe. The difference between transmitted and received frequency is represented by swishing sound, which indicates blood flow. Air between probe and skin can interfere with readings, thin jelly is used for better results. Only Systolic pressures can be recorded.

Invasive pressure monitoring :

Invasive pressure monitoring

Equipment of pressure monitoring :

Equipment of pressure monitoring

Equipment for PM line :

Equipment for PM line

PM system parts :

PM system parts intra-arterial catheter / CVC Semi-rigid pressure tubing Transducer Transducer cable Flush system – hepsaline @ pressure 300mmHg Intraflow valve- cont. flow of flush solution (approximately 3-5 ml/hr ) Fast flush device – for performing a square wave test .

Technical Aspect Of PM System :

Technical Aspect Of PM System Hydrostatic pressure :- pressure on transducer d/t fluid in PM system .it can be eliminated by Leveling the transducer to the phlebostatic axis. Atmospheric pressure :- Zeroing the monitor eliminates the effect of atmospheric pressure on the pressure readings. Zeroing :- Process is to expose the transducer to Atm pressure by opening the adjacent stopcock to air, pressing the zero pressure button on the monitor. Phlebostatic axis: The approx anatomic location of the heart, located at the 4 th ICS, halfway between the anterior and posterior chest wall.

Zeroing Of PM System :

Zeroing Of PM System

Understand dynamic pressure principle:

Understand dynamic pressure principle

Resonance ,Damping , natural frequency :

Resonance ,Damping , natural frequency RESONANCE :- occur in system, Depending on the input frequency, the output may go through an amplification as it reaches a specific frequency, known as the resonant frequency of the system. To prevent amplification :- noncompliant (i.e., stiff) tubing, and mass of liquid in tube should be minimized, which can be accomplished by having small-diameter tubing and as short a length as possible Damping :- a reduction in the amplitude of an oscillation as a result of energy being drained from the system to overcome frictional or other resistive forces. DAMPING coefficient :- related to amplitude of successive oscillation peaks .i.e. Amplitude ratio.

Arterial – LINE (“A” line ) :

Arterial – LINE (“A” line )

Arterial BP (ABP):

Arterial BP (ABP)


41 Introduction Arterial Line:- Teflon catheter inserted into an artery that is connected to a pressure transducer system. Transducer convert mechanical energy into electrical energy and electrical activity shows on monitor . Advantages-Continual beat –to-beat monitoring of blood pressure, and continual vascular access for blood sampling.


INDICATION FOR “A” LINE Critical Pt. with compromises cardiac output , tissue perfusion, or fluid volume status. Pt with Unstable hemodynamics in ICU Multiple blood gas analysis Hypotension or hypertension requiring vasoactive drugs Respiratory illness or mechanical ventilation requiring frequent blood gases: >3X/D for arterial sticks >5X/D for combined arterial and/or venous sticks Major Surgery: Especially CV or Neuro procedures

Pre requisites before “A” canulation:

Pre requisites before “A” canulation W/I consent for procedure Rule out contraindication for A - line Site selection Allen’s test Equipment check

Contraindication :

Contraindication Absence of collateral flow Raynaud's disease and peripheral vascular Dz. Angiopathy, coagulopathy (deranged coagulation , atherosclerosis - Use Caution! Avoid locating near A-V fistula, and inserting through synthetic graft Diabetics at increased risk of complications Avoid local infection, burn or traumatic sites Avoid extremities with carpal tunnel syndrome

Allen’s Test :

Allen’s Test Used to establish the +nce of collateral arterial blood flow through the PALMAR ARCH via the ULNAR artery.

How to perform Allen's test:

How to perform Allen's test Color return to normal < 5 sec

Result can Be …….:

Result can Be …….

Overview of Arterial Line Set Up:

48 Overview of Arterial Line Set Up Equipment needed: 500cc bag 0.9% NS, Transducer tubing, #20 angiocath, dressing supplies, dead end caps. Ensure ALL air removed from system to include flush bag and stopcocks. Inflate pressure bag to 300mm. Purpose of pressure bag is to provide a continuous saline flush at 3-6cc/hr that will overcome the patient’s systolic blood pressure.

Sites for Arterial Lines:

49 Sites for Arterial Lines Can be place in any peripherally palpating artery Radial Artery(most frequently used)-20 G Brachial Artery Femoral Artery – 18 G Ulnar artery Dosalis paedis artery posterior tibial arteries are generally for pediatric.

Sites for A line cannulation :

Sites for A line cannulation Site Advantage disadvantage Radial “A” line easy to cannulate ,accessible during surgery, good collateral circulation patient comfort , Allen ’ s test thrombus formation, possible injury to nerve, augmentation of SBP, Brachial “A” line easy to cannulate, larger catheter, less SBP augmentation , collateral + uncomfortable for pt, median nerve damage Femoral “A” line Kept prolonged & useful in shock pt largest catheter atherosclerotic plaque may break off, massive hematoma ,pt discomfort . Axillary “A” line large size useful in peripheral artery dz and shock ,proximity to aorta neurologic complication, technically difficult Dorsalis paedis artery dual circulation greatest SBP augmentation Thrombosis, impossible to walk

Overview of mechanics :

Overview of mechanics

“ A” line Monitoring:

52 “ A” line Monitoring Transducer leveling at (phlebostatic axis) Zeroing the PM system monitor Once zeroed, turn stopcock back and recap it . Monitor will display arterial waveform . Represents the ejection phase of the left ventricular systole. As the aortic valve opens, blood is ejected and recorded as an increase in pressure in the arterial system Dicrotic notch represents aortic valve closure and signifies the start of diastole. Highest peak –SBP , lowest point - DBP

Arterial Waveform:

53 Arterial Waveform 1, Systolic upstroke; 2, systolic peak pressure; 3, systolic decline; 4, dicrotic notch; 5, diastolic runoff; 6, end-diastolic pressure

The Pressure-pulse:

The Pressure-pulse 1st shoulder (the Inotropic Component): early systole, opening of aortic valve, transfer of energy from contracting LV to aorta 2nd shoulder (the Volume Displacement Component): produced by continuous ejection of stroke volume from LV, displacement of blood, and distention of the arterial wall Diastole: when the rate of peripheral runoff exceeds volume input to the arterial circulation

Information gained from a pressure waveform:

Information gained from a pressure waveform Systolic, diastolic, and mean pressure Myocardial contractility (dP/ dt ) Peripheral vascular resistance (slope of diastolic runoff) Stroke volume (area under the pulse pressure curve) Cardiac output (SV x HR ) Is arterial waveform predictive of cardiac contractility? It is only “ aortic arch pressure ” that can be used to measure LV contractility, not “ peripheral pressure ”

Arterial waveform interpretation :

Arterial waveform interpretation

Dynamic Response testing:

Dynamic Response testing Square Wave or Fast Flush Test Valve Open Valve closed Square-wave test: A series of rapid fast-flushes of the hemodynamic monitoring system used to assess the system’s response to sudden large changes in pressure. Use of the square-wave test to calculate the dynamic response is the most accurate way to make decisions about the reliability of the monitoring system.

Dynamic performance testing - Indications:

Dynamic performance testing - Indications At initiation Waveform is distorted Physiological changes in the patient Before implementing any intervention When accuracy is in doubt Atleast every 8-12 hrs

Normal flush test :

Normal flush test

Under damping :

Under damping

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Under damping High SBP Low DBP Same MAP Long tubing Increased vascular resistance Narrow peaked tracing Hypertension, atherosclerosis, Vasoconstriction, aortic regurgitation, Hyperdynamic states like fever .


Too many stopcocks Long tubing Air bubbles Defective transducer UNDERDAMPED WAVEFORM

Under damping :

Under damping Tracing give false high SBP and a false low DBP Underdamping occur when natural freq of system is identical to freq of pressure wave transmitted by pt . When this happens the tubing vibrates more intensely, CLINICAL APPLICATION:- An underdamped arterial monitoring system can delay identification of hypovolemia in patients recovering from surgery or trauma. The normal hemodynamic response to hypovolemia is vasoconstriction, identified clinically by a narrowed pulse pressure. Narrowing of the pulse pressure occurs long before hypotension appears. If the patient has an underdamped arterial monitoring system, the narrowed pulse pressure and early decreases in systolic blood pressure may go unrecognized. This may result in failure to intervene appropriately, and the patient may experience hypovolemic shock.

Over damping :

Over damping

Over damping :

Over damping Potential sources of overdamping include Distensible tubing – use only the semi-rigid tubing Short extension tubing –tubing should never exceed 3 – 4 feet in length. Air bubbles in the circuit – check stopcocks and connections with meticulous care, as air bubbles tend to cling to these components. Small diameter catheters, long catheters, and soft, compliant catheters can all cause overdamping. CLINICAL APPLICATION:- Because of unawareness of overdamping a hypertensive pt could have disastrous consequences like an intracranial or aortic aneurysm , and pt may not receive appropriate interventions to manage their blood pressure .


Air bubble/blood in line Clot Disconnected/loose tubing Underinflated pressure bag Catheter tip against wall Compliant tubing DAMPENED WAVEFORM

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Over Damping Lower SBP Higher DBP Same MAP Air bubbles Overly compliant tubing Blood clots / Fibrin Catheter kinks Stopcocks / Injection ports No fluid in flush bag / Low flush bag pressure Widened slurred tracing Aortic stenosis, vasodilatation, low cardiac output states like Cardiogenic shock, sepsis or severe hypovolemia.

Optimization of natural frequency:

Optimization of natural frequency Wide bore, high pressure tubing no longer than 122cm( 48”) Avoid tubing extentions, stopcocks All connections are tightened Eliminate air bubbles Clear the tubing of any fluid other than NS. Continuous flush bag with external pressure of 300mmHg Keep cannulated extremity in neutral or slightly extended position

Arterial Waveform and Progression of the Pulse wave:

Arterial Waveform and Progression of the Pulse wave   Distal pulse wave amplification of the arterial pressure waveform. and wider pulse pressure

Distal pulse amplification :

Distal pulse amplification The systemic pulse wave propagates from the aortic valve at 6–10 m/s. During its passage into the peripheral vasculature there is a progressive increase in systolic (SBP) and reduction in diastolic blood pressures (DBP), as standing and reflected waves become incorporated into the waveform, a process known as distal pulse amplification. MAP is more valuable than SBP & DBP 1. MAP is least dependent on measurement site or technique (invasive versus non-invasive). 2. MAP is least altered by measurement damping. 3. MAP determines tissue blood flow via autoregulation (apart from the left ventricle, which autoregulates from DBP).

As BP is measured farther into periphery::

As BP is measured farther into periphery: The anacrotic and dicrotic notches disappear The waveform appears narrower The systolic and pulse pressure increase The upstroke becomes steeper The diastolic pressure decrease MAP remain most reliable parameter

Morphology changes as a result of peripheral reflexions:

Morphology changes as a result of peripheral reflexions Reflexion of waves due to the tapering diameter Reflexion due to changing content of the arterial wall Reflexion also occur at branching points of vessels

Care and Maintenance:

73 Care and Maintenance Assess color, movement, pulse, temperature, and sensitivity of extremity where line is in place. Zero transducer with position changes. Ensure transducer at phlebostatic axis.

Position and Fixation of arterial cannula:

Position and Fixation of arterial cannula

Arterial pressure tracing interpretation :

Arterial pressure tracing interpretation 1. How will an arterial pressure tracing change in atrial fibrillation? The rise in pressure will have the same pattern of irregularity as the R-R interval. The systolic pressure will vary, with the lowest pressure occurring after the shortest R-R interval indicating reduced stroke volume from reduced filling volume (shortened diastolic time). If several very short R-R intervals appear in a row, the stroke volume may be extremely reduced (or negligible), indicating the accumulative effect of several cycles of reduced filling time. 2. How will an arterial pressure tracing change with frequent PVCs? Every premature beat will result in a premature systolic rise. The rise associated with the premature beat will usually have a decreased amplitude (lower stroke volume), because of the shortened preceding filling time.


CALIBRATION The accuracy of blood pressure measurement requires an accurate reference point that is the patient mid axillary line Zeroing process is done by closing the patient side and opening the other end of the three way to the atmosphere Now press zero


TIPS FOR MAINTAINING ACCURATE MONITORING ↓ number of stopcock, limit extension tubing length , because it may be source of leak, contamination and air bubble collection . Use short, non-compliant connecting tubing. Standard I.V tubing is too compliant (soft), and absorbs waveform energy, causing overdamping. Short tube (< 3-4 feet) increases the natural frequency of the monitoring system and lessens the chance of under damping. Maintain tight connections. Inspect connections frequently for fluid leaks. Keep connections as visible as possible. Luer-lock ↓ risk of accidental disconnection. Maintain the fast flush system. Pressure bags frequently loose pressure. Check that the pressure is maintained at 300 mm Hg during routine monitoring of the system and any time the pressure reading is in question. An increase in the frequency of fast flushes may be necessary to maintain system patency in hypercoagulable patients. Inspect for bubbles. Carefully inspect all fluid-filled components after setup and periodically thereafter. Even pinpoint air bubbles affect the accuracy of the system.


CVC Big Lines for Big Problems



Central vein ( valve less ) :

Central vein ( valve less ) (1) Basilic vein (2) Subclavian vein (3) External jugular vein (4) Internal jugular vein (5) Brachiocephalic vein (6) Superior vena cava (7) Atrium (8) Azygos vein

What is cvp ?:

What is cvp ? CVP is the pressure measured at the junction of the superior vena cava and the right atrium. It reflects the driving force for filling of the right atrium & ventricle. It reflects the relationship of blood volume to the capacity of the venous system.


CVP Normal CVP in an awake , spontaneously breathing patient - 1-7 mmHg or 5-10 cm H 2 O. Changes with respiration : Normally the JVP/CVP falls with inspiration as the decrease in intrathoracic pressure is transmitted to the right atrium Mechanical ventilation- 3-5 cm H 2 O higher. (Note:10 cmH 2 0 = 7.5mmHg =1kPa)

Methods to measure cvp:

Methods to measure cvp 1. Indirect assessment- Inspection of jugular venous pulsations in neck. 2. Direct assessment- Fluid filled manometer connected to central venous catheter. Caliberated transducer.

Inspection of JVP :

Inspection of JVP The JVP can be estimated by observing the level of blood in IJV .The normal waveform has 2 peaks per cycle, which helps distinguish it from the carotid arterial pulse. The sternal angle is approx 5 cm above the RA , so the normal JVP should be no more than 4 cm above this angle when the patient lies at 45°. If the JVP is low, the patient may have to lie flat for it to be seen; if high, the patient may need to sit upright. Abdomino-jugular reflux:- Gently press over the abdomen for 10 seconds. This increases venous return to the right side of the heart temporarily and the JVP normally rises. This rise may take 15 seconds to decrease in congestive heart failure

Methods to measure cvp contd...:

Methods to measure cvp contd... Inspection of jugular venous pulsations in neck. No valves b/w RA & IJV. Degree of distention & venous wave form –information about cardiac function.

Fig. showing measurement of jvp:

Fig. showing measurement of jvp

JVP interpretation :

JVP interpretation Condition Abnormality Heart failure Elevated and sustained Abdomino-jugular reflex Pul embolism Elevated Pericardial effusion Elevated and prominent ‘y’ descend Pericardial constriction Elevated and kussmaul’s sign ( paradoxical rise in JVP o n inspiration because right heart chambers cannot increase in size due to restriction by fluid or pericardium ) SVC compression Elevated and loss of pulsation Atrial fibrillation Loss of ‘a’ wave Tricuspid stenosis , Pul HTN Giant ‘a’ wave Tricuspid regurgitation Giant ‘v’ wave Complete heart block ‘Cannon’ wave


INDICATIONS FOR CVC Central venous pressure monitoring Pulmonary artery catheterization & monitoring Transvenous cardiac pacing Temporary hemodialysis Drug administration Conc. Vasoactive drugs Hyper alimentation Chemotherapy Agents irritating to peripheral veins Prolong antibiotic therapy


INDICATIONS CONTD…… 6. Rapid infusion of fluids Trauma Major surgery 7. Aspiration of air emboli 8. Inadequate peripheral intravenous access 9. Sampling site for repeated blood testing

CVC Placement Technique and Approaches :

CVC Placement Technique and Approaches

Different Routes To access central vein:

Different Routes To access central vein Internal jugular vein Subclavian vein Femoral vein Basilic vein (antecubital fossa ) Axillary External jugular Brachial Cephalic Brachio cephalic ( supra – clavicular approach ) rarely used veins - Commonly used veins-

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                                                                                                Anatomic landmark of IJV

IJV central venous catheterization :

IJV central venous catheterization Positioning Right side preferred Trendelenburg position ( 10-15 degree) Head turned slightly away from side of venipuncture Needle placement: Central approach Locate the triangle formed by the clavicle and the sternal and clavicular heads of the SCM muscle Gently place three fingers of left hand on carotid artery Place needle at 30 to 40 degrees to the skin, lateral to the carotid artery Aim toward the ipsilateral nipple under the medial border of the lateral head of the SCM muscle Vein should be 1-1.5 cm deep, avoid deep probing in the neck

IJV Cannulation :

IJV Cannulation Located b/w the sternal & clavicular head of the sternocleidomastoid muscle Lateral to carotid artery Lower incidence of pneumothorax compared to subclavian vein catheterization Right internal jugular vein takes a straight course to right atrium, easier to position at SVC-RA junction Right internal jugular vein catheterization has lower incidence of pneumothorax compared to left due to lower dome of pleura on right side Right internal jugular vein catheterization avoids thoracic duct injury on left More likely to become contaminated due to respiratory secretions

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Internal Jugular Central Approach

IJV Posterior approach :

IJV Posterior approach

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Catheter over guidewire ( Seldinger technique)

Subclavian Approach :

Subclavian Approach Positioning Right side preferred Supine position, head neutral, arm abducted Trendelenburg (10-15 degrees) Shoulders neutral with mild retraction Needle placement Junction of middle and medial thirds of clavicle At the small tubercle in the medial deltopectoral groove Needle should be parallel to skin Aim towards the supraclavicular notch and just under the clavicle

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Subclavian Infraclavicular approach

Subclavian supraclavicular approach :

Subclavian supraclavicular approach Aim towards contralateral nipple

Femoral Vein Cannulation :

Femoral Vein Cannulation Positioning :- Supine Needle placement :- Medial to femoral artery Needle held at 45 degree angle Skin insertion 2 cm below inguinal ligament Aim toward umbilicus

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Femoral Vein Cannulation

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Location Advantage Disadvantage Internal Jugular Bleeding can be recognized and controlled Malposition is rare Less risk of pneumothorax Risk of carotid artery puncture PTX possible Femoral Easy to find vein No risk of pneumothorax Preferred site for emergencies and CPR Fewer bad complications Highest risk of infection Risk of DVT Not good for ambulatory patients Subclavian Most comfortable for conscious patients Highest risk of PTX, should not do on intubated pts Should not be done if < 2 years Vein is non-compressible

The Malposition of Catheter:

The Malposition of Catheter Defined as any cath that is outside the cath tip positioning zone . This zone is SVC from below the level of 1 st rib to above pericardial reflection i.e. the take off of Rt main bronchus

Malposition of CVC :

Malposition of CVC catheter tip is not located in the SVS or IVC catheter forms a loop, in the vessel close to the heart or in the vena cava . catheter tip is advanced too far into the heart, inducing arrhythmias, damaging the right heart valve or even precipitating cardiac tamponade, catheter tip is positioned too close to the vein wall, preventing infusion/aspiration. Recommended Position of CVC tip in SVC and IVC

How to prevent Malposition :

How to prevent Malposition A distance of about 2 cm from the right atrium should be maintained, since this leaves enough space for the catheter tip to move without directly damaging the cardiac atrium. CVC is generally positioned by estimating the length on the patient, according to publish data ; Right subclavian or jugular vein: 13–16 cm Left subclavian or jugular vein: 15–20 cm Peres & co-worker devised the formula for access through the subclavian and jugular vein, while there was insufficient data available for other puncture sites.

Length estimation for CVC :

Length estimation for CVC Insertion site of CVC Length formula in adult (Peres and coworkers ) Rt SC L = H/10 – 2 Rt IJV and EJV L = H/10 Lt IJV and SC L = H/10 + 4 Height of children and juveniles, Length formula of CVC only rt IJV EJV & SC (Andropolous and coworkers) H ≤ 100 cm L = H/10 – 1 H ≥ 100 cm L = H/10 – 2

Malposition possibility in Lt sided CVC:

Malposition possibility in Lt sided CVC

X-Ray -Malposition of CVC :

X-Ray -Malposition of CVC AP fluorography image of a misplaced catheter which was advanced from the internal into the external jugular vein. Fluorography chest image showing a catheter which was erroneously advanced through the internal jugular vein into the subclavian vein.

Looping of CVC :

Looping of CVC

ECG guided placement of CVC:

ECG guided placement of CVC

ECG controlled CVC tip placement :

ECG controlled CVC tip placement Principle :- If the catheter tip is advanced past the SA node into the RA, an abnormal P wave is produced in the intra-atrial ECG. This signal disappears as soon as the catheter is retracted back into the SVC.

How to place ECG guided CVC :

How to place ECG guided CVC

CVC Tip and guidewire :

CVC Tip and guidewire

Ultrasound-Guided Central Venous Access:

Ultrasound-Guided Central Venous Access Becoming standard of care Vein is compressible Vein is not always larger Vein is accessed under direct visualization Helpful in patients with difficult anatomy                                                                                   

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                                                                                                                                                                     Needle entering IJ

PowerPoint Presentation:

                                                                                   Femoral Vein Femoral Artery Compression of vein with US probe

Measurement of CVP:

Measurement of CVP Fluid filled manometer connected to central venous catheter- measured using a column of water in a marked manometer. CVP is the height of the column in cms of H 2 O when the column is at the level of right atrium. Advantage - simplicity to measure. Disadvantage - Inability to analyze the CVP waveform. -Relatively slow response of the water column to changes in intrathoracic pressure.

How to measure the CVP using a manometer system:

How to measure the CVP using a manometer system The CVP system A bag of saline or dextrose = ‘reservoir’ Three way tap - connected to manometer, reservoir and patient’s CVL by tubing; System is primed with fluid before starting Patient is lying supine if possible Manometer has spirit level at ‘zero’; Zero point is aligned with right atrium using the mid axillary line / 4 th ICS Measurements should be taken with the patient in the same position each time using the spirit level; the zero point on the skin surface is marked for consistency of measurement Three way tap Patient position supine on the bed

How to measure the CVP using a manometer system:

How to measure the CVP using a manometer system Turn the three way tap OFF to the patient. Fill the manometer to the top from the reservoir Turn the three way tap OFF to the reservoir This means the column of fluid is supported only by the RAP / CV pressure The column will fall according to CVP The column swings with respiration - conventionally the level is taken as the mean. Three way tap OFF to the patient – allowing the manometer to be filled Three way tap OFF to the reservoir – allowing the CVP to be measured

Measurement of cvp cont…:

Measurement of cvp cont… Caliberated transducer. Automated, electronic pressure monitor. Pressure wave form displayed on an oscilloscope or paper. Advantages- More accurate. Direct observation of waveform. Relationship between water manometer and caliberated transducer in terms of pressure 1cm H 2 O = 0.73 mmHg. Or 1.36 cm H 2 O = 1 mmHg.

Pressure transducer:

Pressure transducer

CVP waveform :

CVP waveform

CVP waveform :

CVP waveform Wave or descend Cause a wave Due to atrial contraction — active push up SVC and into right ventricle (may cause an audible S4) C wave An invisible flicker in the x descent due to closure of the tricuspid valve, before the start of ventricular systole X descend Downward movement of the heart causes atrial stretch and drop in pressure V wave Due to passive filling of blood into atrium against a closed tricuspid valve Y descend Opening of tricuspid valve with passive movement of blood from right atrium to right ventricle (causing an S3 when audible)

Cvp measurement & intrathoracic pressure:

Cvp measurement & intrathoracic pressure CVP measurement is influenced by changes in intrathoracic pressure. It fluctuates with respiration. Decreases -spontaneous inspiration. Increases -positive pressure ventilation. CVP should be taken at the end- expiration . PEEP applied to the airway at the end of exhalation , may be partially transmitted to the intrathoracic structures CVP measured will be higher.

PowerPoint Presentation:

CVP Reading Other clinical features Diagnosis Treatment Low Tachycardia Low normal or hypotension Urine output – oligo or anuria Hypovolemia Fluid challenge until CVP within normal limits and treat underlying cause Low ( may be normal or high due to venoconstriction) Tachycardia Signs of infection Pyrexia Vasodilatation is most common but severe sepsis maybe associated with constriction Sepsis Fluid resuscitation (if low) Antibiotics May require inotrops support Normal – due to Venoconstriction Tachycardia Urine output ‘falling’ below 30ml /hr Poor capillary refill Hypovolaemia Fluid challenge and treat underlying cause High Dyspnoea with pulmonary crepitations Tachycardia with third heart sound Tender hepatomegaly Ascites Peripheral Oedema Heart failure Diuretics, GTN infusion, may require inotrops Very High Venous congestion and dilatation of face and neck; associated signs SVC obstruction Cardiac temponade Tension pneumothorax Treat underlying cause


HIGH READINGS Ventricular failure (R/L) SVC obstruction Tricuspid regurg Tamponade Pulmonary HTN Overload glomerulonephritis


LOW READINGS Vasodilation hemorrhage hypovolemia Addisonian crisis Sepsis Regional anesthesia Polyuria Sympathetic dysfunction

Complications :

Complications Injuries asso with CVC are asso with higher severity than other anaesthesia related complication . Acute complications :- Arterial puncture :- 3% in subclavian 10% in IJV . Carotid puncture – hematoma – tracheal compression / stroke –may lead to death With anatomical land mark complication Carotid artery puncture – 10.6 % ( with USG it ↓4.2%) Hematoma – 8.4% Pneumothorax – 2.4% Hemothorax – 1.7%

Complications contd ….:

Complications contd …. 2. Pneumothorax :- 6% with subclavian 0.5 % with IJV 0 % with Ext jugular Dx with CXR – ideally taken at end of expiration in upright view If penumoTx is suspicious – use of N2O should be limited if possible becoz – N2O diffuse into penumoTx much rapidly than air diffuses out .therefore size of pneumo may double in < 10 min in +nce of 50 % N2O.

Complications contd ….:

Complications contd …. Rt sided site selection preffered becoz- less venous perforation by guidewire , dilator and catheter Lt side cupola of pleura is higher . ARRHYTHMIAS :- Due to mechanical irritation of atria and ventricle caused by guidewire / cath . Treat by withdraw the cath / guidewire . Limiting guidewire depth < 22 cm in Rt IJV . Tip position below clavicle and above 3 rd rib or T4/T5 interspace or tracheal carina .

Complications contd ….:

Complications contd …. Malposition :- defined as any cath that is outside the cath tip positioning zone . This zone is SVC from below the level of 1 st rib to above pericardial reflection i.e. the take off of Rt main bronchus . CVC Tip movement :- Upto 9 cm movt of cvc tip occur with antecubital fossa (PICC) when arm adducted or abducted . Upto 2 cm in subclavian when shoulder move . Upto 4 cm in IJV when neck flex / extend . So when CXR adv underscore the position of arm / neck

Complications contd ….:

Complications contd …. Rough idea of CVC length :- length from placement site to 2 nd rib i.e. sternal notch . Rt IJV = {pt height (Cm)/10 }– 2 Delayed complication:- Sepsis – life threatening complication , M.C organism staph epidermidis

Factors predisposing to perforation of central vein :

Factors predisposing to perforation of central vein Lt sided approach Guidewire without flexible tip Stiff catheter ( 3 lumen >2>1) Malposition Tip in heart Tip not parallel to SVC 5. Long arm CVC

Post-Catheter Placement:

Post-Catheter Placement Aspirate blood from each port Flush with saline or sterile water Secure catheter with sutures Cover with sterile dressing (tega-derm) Obtain chest x-ray for IJ and SC lines Write a procedure note

Procedure Note:

Procedure Note Name of procedure Indication for procedure Comment on consent, if applicable Describe what you did, including prep Comment on aspiration/flushing of ports How did patient tolerate procedure Any complications

Tips :

Tips After 3-4 tries, let someone else try Get chest x-ray after unsuccessful attempt If attempt at one site fails, try new site on same side to avoid bilateral complications Halt positive pressure ventilation as the needle penetrates the chest wall in subclavian approach If you meet resistance while inserting the guide wire, withdraw slightly and rotate the wire and re-advance Align the bevel with the syringe markings Use the vein on the same side as the pneumothorax Withdraw slowly, you will often hit the vein on the way out

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reference Monitoring in Anesthesia and Critical Care Medicine, Hemodynamic monitoring: Invasive and Noninvasive Clinical application, Cullen et al: Interpretation of blood pressure measurement in anesthesia. Anesthesiology , Dorsh & Dorsh Miller 7 th edition

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