Critical Care Obstetrics part 17 pot

Establishing central venous and arterial access are acquired skills that require knowledge of catheter types, access routes, insertion techniques and maintenance.. Peripherally inserted

Ventilator Management in Critical Illness

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Critical Care Obstetrics, 5th edition Edited by M Belfort, G Saade,

Gayle Olson 1 & Aristides P Koutrouvelis 2

1 Department of Obstetrics and Gynecology, Division of Maternal - Fetal Medicine, University of Texas Medical Branch, Galveston, TX, USA

2 Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, USA

Introduction

Placement and maintenance of vascular access can be an

impor-tant adjunct in the care of the critically ill obstetric patient

Arterial and venous access affords the clinician several advantages

(Table 10.1 ) Long - term central intravenous (IV) access may also

be indicated for gravidas with coexisting disease such as those

illustrated in Table 10.2 , for the administration of parenteral

nutrition, drugs, or antibiotics [1 – 4]

Establishing central venous and arterial access are acquired

skills that require knowledge of catheter types, access routes,

insertion techniques and maintenance

Catheter t ype

Choosing the venous catheter type and the site for insertion are

infl uenced by indication (Table 10.2 ), duration of use, urgency

of administration, and the composition of infusate (i.e.,

osmolar-ity, tonicosmolar-ity, crystalloid, colloid) Catheters with shorter lengths

and larger diameters allow for more rapid fl ow rates For example,

coupling of tube diameter (0.71 mm or 22 gauge vs 1.65 mm or

16 gauge) results in almost a quadrupling of the fl ow rate (25 mL/

min vs 96 mL/min) [5] Multilumen catheters are routinely used

for central venous cannulation (Figure 10.1 ) The more

com-monly used triple - lumen catheter has an outside diameter of

2.3 mm (6.9 French) and provides three channels (three 18

gauge, two 18 - gauge plus one 16 - gauge) The opening of each

channel is separated from the other by 1 cm or more in order to

reduce mixing of infusates

Intravenous catheters are considered to be short - or long - term

transcutaneous, or implantable subcutaneously (Table 10.3 ) as

well as peripheral or central A peripheral location is distal to a

central vein and contains valves In contrast, a centrally located catheter contains no valves and is considered to be at the level of the axillary or common femoral vein, and all other veins oriented toward the heart from this level The use of the terminology “ peripheral ” and “ central ” is also based on the peripheral or central location of insertion and the location of the catheter tip Central vein cannulation is required to accommodate the large bore catheters necessary for high - volume administration rates When administering highly osmolar, sclerotic, or thrombotic IV

fl uids, most clinicians agree that the catheter tip should be placed near the heart in the superior or inferior vena cava, although optimal placement has not been established in prospective human studies [6]

Short - term (less than 2 weeks) transcutaneous catheters are constructed of polyethylene, polyurethane, polycarbonate, vinyl chloride, or silicone and are available in multiple lengths, diam-eters, and lumen numbers Short - term transcutaneous catheters are suitable for most obstetric patients in the “ diffi cult access ” group (i.e history of IV drug abuse, IV chemotherapy, hypovo-lemia) and for others with rapidly resolvable clinical conditions Because of the intended short duration of use, sites on the lower extremities, such as pedal, saphenous, and femoral veins, might

be selected; however, decreased mobility and increased risk of catheter dislodgement are among the disadvantages of lower extremity access locations

Long - term (weeks to months) transcutaneous catheters are usually constructed of more fl exible and less thrombogenic deriv-atives of silicone, and are passed through a subcutaneous tunnel between the points of venous insertion and exit from the skin [7,8] Frequently, these catheters incorporate a Dacron cuff just proximal to the skin exit site Catheter tunneling and the Dacron cuff promote tissue ingrowth and fi xation and limit the spread of skin exit - site colonization or infection Long - term catheters may incorporate a Groshong valve tip [9,10] Such catheters are blind ended, but incorporate a side slit near the catheter tip Positive pressure exerted through the catheter blows the slit walls open outwardly for fl uid or medication administration, while negative

Vascular Access

the catheter is closed, theoretically obviating the need for hepa-rinization between periods of catheter use Venous sites com-monly used for long - term catheter use include the subclavian, external and internal jugular, basilic, and greater saphenous veins When the femoral, greater saphenous, or basilic veins are used, the catheter is tunneled to allow for port placement onto the lower chest, abdominal wall, thigh or forearm [11]

Peripherally inserted central venous catheters (PICCs), intro-duced in 1975 [12] , are increasingly popular due to the ease of insertion compared with traditionally placed surgical catheters (e.g Hickman ports, central venous ports) with potentially fewer complications [13]

Totally implantable venous access systems (TIVAs), generi-cally known as portacath, utilize catheters attached to reservoirs placed into subcutaneous pockets These systems are indicated for very long - term use (months to years), typically in patients requiring intermittent medications During catheter use, the res-ervoir is accessed with the use of a special Huber - point needle that uses a non - coring tip Though surgical insertion is required for implantable catheters, the early and late complications asso-ciated with venous access are reduced with implantable catheters [14] Ideally, reservoirs for implantable catheters should be placed in a secure, fl at, non - mobile area, preferably overlying a rib

Arterial catheters should be used for specifi c purposes and for short time intervals Arteries that are accessible to palpation and that can usually be cannulated include (in order of preference) the radial, dorsalis pedis, femoral, axillary, and brachial In general, for an artery to be suitable for continuous monitoring of intraarterial pressures: (i) the diameter should be large enough to accommodate the catheter without occluding the lumen; (ii)

Table 10.1 Advantages of vascular access in the critically ill obstetric patient

blood pressure monitoring frequent arterial sampling Central venous Rapid fl uid and blood administration

Hemodynamic monitoring

Table 10.2 Indications for prolonged venous access

Parenteral nutrition and drug therapy

Hyperemesis gravidarum

Infl ammatory bowel disease

Gastroparesis

Pancreatitis

Cystic fi brosis

Short bowel syndrome

Heparin (heart valves, deep vein thrombosis)

Antibiotics (bacterial endocarditis, osteomyelitis)

Chemotherapeutic agents for malignancy

Magnesium sulfate

Lack of peripheral access

Previous intravenous drug abuse

Previous prolonged chemotherapy

Hemodialysis

Figure 10.1 Multilumen catheter insertion set - up

From left to right: small fi nder needle, larger needle,

guidewire, scalpel, dilator, triple lumen catheter,

anchor and suture

Chapter 10

well on dirty skin [20,21] The most popular antiseptic agents are chlorhexidine gluconate and the povidone - iodine preparation betadine Betadine is a water - soluble complex of iodine with a carrier molecule Iodine is slowly released from the carrier mol-ecule, thus reducing any irritating effects Due to this slow release, the preparation should be left in contact with the skin for at least

2 minutes [20 – 22] In one study, a 2% aqueous solution of cho-rhexidine gluconate demonstrated superior antiseptic properties compared to 10% providone - iodine and 70% alcohol [16] However, different concentrations of chorhexidine gluconate may not have the same effi cacy Shaving at catheter insertion sites

is not recommended as it abrades the skin and promotes bacterial colonization If hair removal is necessary, it should be clipped After the catheter has been inserted and secured, a dressing should be placed over the site Gauze or transparent dressings may be used as both approaches have similar rates of catheter related infection

Catheterization t echniques – g eneral

Three catheterization techniques are available to obtain vascular access: direct, modifi ed and classic Seldinger techniques The direct approach involves palpation and direct needle puncture, usually with the advancement of a Tefl on catheter over the needle and into the vessel The Seldinger [23] technique involves the use

of a guidewire This approach is used to replace the needle during percutaneous arteriography Once the vessel has been punctured and the return of blood fl ow (pulsatile in cases of arterial

punc-there should be adequate collateral circulation; (iii) the site

should be such that catheter care can be facilitated; and (iv) the

site should not be prone to contamination

Preparing for c atheter i nsertion

Before cannulation of any vessel, it is necessary to assure patency

of the vessel Contraindications to vessel cannulation include

infection or infl ammation at the site, arterial – venous or

aneurys-mal aneurys-malformations, and arterial graft Coagulopathy is a relative

contraindication to cannulation In the presence of coagulopathy,

the use of Doppler to identify the location of vessels reduces

complications Catheter insertion has been demonstrated in 242

patients with corrected coagulopathy and 88 with uncorrected

coagulopathy In these cases, most bleeding after cannulation was

controlled with a suture at the catheter insertion site, and the only

variable signifi cantly associated with a bleeding complication was

a platelet count < 50 × 10 9 /L (P = 0.02) [15] In addition, local

pressure and use of topical thrombin spray may be used to control

peripheral but not central bleeding

Skin p reparation

Cutaneous antisepsis is paramount This includes but is not

limited to handwashing, education of personnel, and the use of

sterile technique to include large sterile drape, gown and gloves

[16 – 19] Antiseptic agents that reduce skin microfl ora for skin

preparation include alcohol, iodine, chlorhexidine gluconate, and

hexachlorophene Alcohol has a broad spectrum of antibacterial

Table 10.3 Central venous catheter types

Venous site Peripheral

Pedal Saphenous Femoral

Central Subclavian External jugular Internal jugular Cephalic Facial Saphenous Femoral

Same as central long term

Huber point needle required for access to reservoir

Risks/benefi ts Dislodgement of catheter

Decreased patient mobility

Vascular Access

wire is inserted through the needle and into the lumen of the

vessel The sharp needle is then removed and a polyurethane - type

catheter is threaded over the wire and into the vessel Commercially

produced catheters that incorporate an integral guidewire and

employ the modifi ed Seldinger technique are also available

Beards and associates [24] compared these three insertion

tech-niques in 69 critically ill patients The direct puncture technique

was associated with the highest failure rate, followed by the

modi-fi ed and classic Seldinger techniques, respectively The direct

puncture technique also took signifi cantly longer, used more

catheters, and required more punctures per successful insertion

than did the modifi ed or classic Seldinger techniques These

authors also observed that polyurethane catheters were signifi

-cantly less likely to block and require reinsertion than were the

Tefl on catheters As a result, they strongly endorsed use of the

classic Seldinger technique and polyurethane catheters

During catheterization, proper positioning of the patient is

important The patient should be in the Trendelenburg position

and rolled slightly to the left in the later stages of pregnancy when

the inferior vena cava is susceptible to compression by the

enlarged uterus If the patient is intolerant of the Trendelenburg

position, the legs can be raised Local anesthetic is infi ltrated into

the site for needle insertion, incisions or dissection for

subcutane-ous pockets After vensubcutane-ous puncture, the syringe is removed

care-fully, while the operator covers the needle hub to prevent excessive

bleeding and entry of air Covering the needle hub is especially

important with central venous punctures With the Seldinger

technique a guidewire is placed through the needle, and the

needle is withdrawn Next, a stiff dilator is generally threaded

over the wire and passed one or more times in order to dilate the

tract to the vein, after which a dilator – catheter assembly is

threaded over the wire into correct position, and the wire and

dilator are removed Correct placement is supported by confi

rm-ing free aspiration of blood from the catheter and free fl ow (by

gravity alone) of an appropriate crystalloid solution through the

catheter

Long - term transcutaneous catheters are generally placed using

a peel - away sheath modifi cation of the Seldinger technique After

dilation of the tract, a dilator – sheath assembly is advanced over

the wire into the chosen vein, and the wire and dilator are

removed A Silastic catheter is then threaded through the peel

away sheath Upon proper positioning, the handles on the peel

away sheath are rotated perpendicular to its long axis until the

sheath cracks Pulling the sheath handles apart, the sheath is then

simultaneously peeled in half along its long axis and removed

while the catheter is carefully held in place

In cases of arterial cannulation, successful line placement can

be confi rmed by the appearance of pulsatile blood fl ow or, if any

doubt exists, by blood gas analysis Vessels suitable for

cannula-tion include radial, femoral, brachial, axillary, dorsal pedis and

superfi cial temporal arteries For blood pressure monitoring, the

catheter is connected to a transducer with a three - way stopcock

and high - pressure tubing which is connected to a pressure bag

containing normal saline and heparin (1500 U/500 mL) The

high - pressure tubing is necessary to prevent damping of blood pressure readings The heparinized saline is administered through the pressurized bag at a rate of approximately 2 – 5 mL/h to prevent the catheter from clotting off It is critically important to purge all pressure lines and stopcocks before connecting the arterial line

to prevent arterial air embolism All set - ups should also have a purge or fl ush device that can be used to clear any blood that may back up into the pressure tubing as well as to clear the catheter itself and the stopcock after blood sampling Complications of arterial cannulation include vessel spasm, infection, thrombosis, bleeding, and hematoma

Special t echniques for c atheter i nsertion

Several authors have described utilizing real - time ultrasound to facilitate the location of a vein and to lessen the incidence of mechanical complications related to central catheter insertion [25,26] The use of ultrasound during the central venous access placement, particularly in diffi cult patients, is becoming more commonplace The placement of the transducer in the area of interest, whether internal jugular (Figure 10.2 ) or femoral, facili-tates identifi cation of the venous vessel The dramatic enlarge-ment of the superior vena cava during a Valsalva maneuver readily identifi es the enlarged and yet compressible venous vessel

as compared to the non - compressible, pulsating artery

Schummer et al conducted a study demonstrating a mechani-cal complication rate of 12% during catheter insertion using the Seldinger technique [27] The complications encountered by this experienced group included inadvertent arterial puncture, pneu-mothorax, malposition, and failed cannulation Ultrasound has the potential to decrease this complication rate Fluoroscopic guidance has also been reported to be of assistance with catheter placement Finally, right arterial electrocardiography can be used

to facilitate proper catheter tip placement [6]

Complications – g eneral

A wide range of immediate and delayed complications can be associated with central venous and arterial catheters (Tables 10.4 & 10.5 ) Specifi c complications related to catheter use are dis-cussed individually within each subsection

Catheter m alposition

Catheter malposition can be a complication of any vascular can-nulation Optimal catheter tip location has not been established via prospective human studies but most practitioners believe the superior vena cava, proximal to the right atrium, to be the ideal location [6] Catheter tips located in smaller, more proximal veins are more likely to be associated with venous thrombosis and stenosis, while catheter tips positioned in the heart may be associ-ated with cardiac arrhythmias, perforation, tamponade, valvular injury, or endocarditis PICC catheter tip malpositioning from an

Chapter 10

Carotid Artery

Right I.J

Figure 10.2 Ultrasound image of the IJV The IJV

can be visualized beneath the sternocleidomastoid muscle and adjacent to the carotid artery

Table 10.4 Complications of central venous catheters

Hydrothorax/chylothorax Catheter dislodgement/breakage

Tracheal/esophageal injury Catheter - related infection

Brachial plexus injury Cardiac perforation

Recurrent laryngeal nerve injury Clavicular osteomyelitis

Table 10.5 Complications of arterial catheters

Hematoma

Hemorrhage

Catheter occlusion

Catheter dislocation

Infection

Embolism

Ischemic injury

Thrombosis

Pseudoaneurysm

Arteriovenous fi stula

antecubital approach is the most frequently seen with a rate of

21 – 55% [28] Among the most devastating consequences of cath-eter malposition is cardiac tamponade This uncommon yet potentially catastrophic complication must be considered after insertion of all central catheters Postinsertion chest radiographs are universally recommended, with possibly the exception of the image - guided central venous catheter insertion [29 – 32] These radiographic studies should demonstrate midline placement of the catheter tip in the center of the SVC, and not abutting the arterial or ventricular wall

Thrombosis, s tenosis and o cclusion

Thrombosis of the great veins is frequently asymptomatic and therefore under - recognized and under - reported [33] In SCV catheterization, the complication is clinically diagnosed with a frequency of less than 5%, but is diagnosed by contrast venogra-phy in 20 – 40% of patients [29] Thrombosis appears to be related

to several factors The fi rst consideration is the relative diameters

of the catheters and vessel Generally, the smaller the diameter of the catheter relative to the vessel size, the lower the incidence of thrombosis Additional factors include duration of use, catheter material, shape of catheter tip, number of cannulation attempts, low cardiac output, hypotension, use of vasopressors, peripheral vaso - occlusive processes, and Raynaud ’ s disease [24,34]

Catheter occlusion can result from the formation of a fi brin plug at the catheter tip This is part of a fi brin sleeve that forms around essentially all IV catheters present for more than a week [29,35]

When withdrawing blood samples, the dead space in the system should be appreciated, and a suffi cient quantity of blood

to account for this should be withdrawn and discarded before

Vascular Access

maintained in a 20 – 30 ° Trendelenburg position This maintains the head in a “ down ” position, distending the IJV and minimizing air entrapment A trianglular region created by two heads of the SCM and the clavicle is then identifi ed (Figure 10.3 ) The carotid artery is palpated medial to the IJV and medial and posterior to the SCM and is retracted medially An 18 - gauge cannulating needle, attached to a syringe, is inserted at the apex of the triangle, bevel facing up, and at a 30 – 45 ° angle to the skin (Figure 10.4 ) The needle is advanced toward the ipsilateral nipple If the vein

is not encountered by a depth of 5 cm, the needle is withdrawn

4 cm and advanced again in a more lateral direction When a vessel is entered a fl ash of blood is noted at the catheter hub If the blood is pulsating, you have entered the carotid artery In this situation, remove the needle and tamponade the area for 5 – 10 minutes When the carotid artery has been punctured, no further attempts should be made on either side because puncture of both arteries can have serious consequences

system after specimen collection, lest the line clot off Clots

adherent to the catheter tip, or even the vessel lumen, can be

dislodged during fl ushing Flushing protocols, with and without

heparin, have been devised to reduce catheter thrombosis [33,36]

The use of a fi brinolytic agent administered through the catheter

has also been shown to be successful in reopening thrombosed

catheters [37 – 41] Additional treatment of catheter - related deep

vein thrombosis may also involve catheter removal [42,43]

Embolism

Air embolism is a rare but potentially fatal complication of central

venous catheters with an estimated incidence of less than 1% but

with a mortality rate as high as 50% If the air embolus is of the

magnitude of 50 mL or greater, the outcome is more likely to be

fatal Symptoms of an air embolus can include seizures,

hemipa-resis, and focal neurologic signs An air embolus may be reduced

by aspirating through the central line or placing the patient in

Trendelenburg and in the left lateral decubitus position in the

hopes of containing the air in the right ventricle until other

mea-sures can be enacted In stable patients, treatment can be

sup-portive and include administration of 100% oxygen Rewiring

central venous catheters can also be particularly hazardous

Attention to technique and position must also be employed

during this seemingly innocuous procedure

Vesely [44] reviewed complications for 11 583 central venous

catheter insertions Air embolism only occurred in 15 cases, the

majority of which had undetectable, mild, or moderate

symp-toms that resolved with supplemental oxygen Only one case in

their series was fatal

Specifi c v enous a ccess s ites

Internal j ugular v ein ( IJV )

The IJV is located under the sternocleidomastoid muscle (SCM),

and, at its junction with the subclavian vein (SCV), helps form

the brachiocephalic vein Anatomic variation in the course of the

IJV has been noted, and the relationship between the IJV and the

carotid artery may be abnormal in 10% of the population [45]

Typically, when the head is turned away from the intended side

of cannulation, the IJV forms a line from the pinna of the ear to

the sternoclavicular joint and brings the IJV to a more anterior

position relative to the carotid artery [8,46] The IJV is a common

route for central venous access Its advantages include the ease by

which this vessel can be compressed in the case of hemorrhage

and the decreased risk of pneumothorax The right IJV is

pre-ferred because the thoracic duct is avoided as well as providing a

more direct course to the right atrium [45] The anatomic

rela-tionship of the left IJV to the left brachiocephalic vein makes it

diffi cult to negotiate vessel angles and increases the risk of

steno-sis and thrombosteno-sis

Two insertion techniques, the median and posterior approaches

are available for IJV cannulation With the median approach the

head is turned away from the cannulation site with the body

Figure 10.3 Positioning for internal jugular vein cannulation The head is

turned away from the insertion site A triangle is formed by the junction of the heads of the SCM at the apex, and their insertions at the clavicle

Figure 10.4 Anterior approach to internal jugular vein cannulation The carotid

artery is palpated and retracted medially while the needle is inserted at the tip of the triangle and advanced toward the ipsilateral nipple

Chapter 10

Neurologic complications are rare, but have been documented

in association with IJV catheterization The close anatomic rela-tionship between the lower brachial plexus and the IJV can con-tribute to the potential for nerve damage, and is more commonly associated with a traumatic cannulation attempt [50]

External j ugular v ein ( EJV )

The EJV is formed by the junction of the retromandibular and posterior auricular veins It runs obliquely across the SCM along

a line extending from the angle of the jaw to mid - clavicle The EJV joins the SCV at an acute angle under the area of the clavicle [46] The primary advantage of using the EJV for venous access

is the decreased risk of pneumothorax The disadvantages include diffi culty in advancing a catheter, and vein perforation due to the acute angle with the SCV

The patient is placed supine or in the Trendelenburg position

and the head is turned away from the side of insertion The vein

can best be identifi ed by applying pressure just above the clavicle and allowing the vein to engorge Unfortunately, even under the best of conditions, 15% of patients will not have an identifi able EJV [51] Once identifi ed, the vein should be stabilized between the thumb and forefi nger at a level midway between the clavicle and jaw and the catheter inserted with the bevel up The length

of the catheter should not exceed 15 cm Undue force at the time

of catheter insertion can result in perforation of the EJV at the angle in which is enters the SCV Manipulation of the shoulder may facilitate passage of the J - wire past the clavicle without asserting undue pressure [52] In addition, upon meeting resis-tance at the EJV - SCV junction, the J - wire can be withdrawn approximately 0.5 cm proximal to the junction The triple - lumen catheter may then be slowly advanced over the J - wire The success

of this maneuver may lie in the smaller diameter of the catheter tip [53,54] Complications of EJV cannulation include thrombo-sis, superior vena cava perforation, and hydrothorax [47,55]

Subclavian v ein ( SCV )

The SCV is often used to gain central access As a continuation

of the axillary vein, the course of the SCV runs underneath the clavicle and along the outer surface of the anterior scalene muscle

At the level of the thoracic inlet, the SCV joins the IJV to form the brachiocephalic vein [8,46] To cannulate the vein, the patient

is placed in the supine position, maintaining a 15% Trendelenburg

position, with the head facing toward the site of insertion and the

arms pronated, slightly fl exed, and down at the sides One helpful approach for catheter insertion is to place a rolled towel under the spine and shoulder This type of positioning serves to widen the path between the fi rst rib and the clavicle Next, the operator should visualize the path of the subclavian artery divided into medial, middle, and lateral thirds along the clavicular line (Figure 10.6 ) Using this method, the junction of the medial and middle segment approximates the lateral aspect of the SCM insertion on the clavicle Using this point for needle insertion may decrease the risk for pneumothorax The bevel should initially be pointing

With the posterior approach, the body position is the same but

the physician should plan an insertion site 1 cm superior to the

point where the external jugular vein (EJV) crosses over the

lateral edge of the SCM In the posterior approach, the needle is

then inserted at the 3 o ’ clock position, with the bevel up, and is

advanced along the underbelly of the SCM and then aimed

toward the SCM at its sternal insertion and the suprasternal notch

(Figure 10.5 ) The IJV should be encountered 5 – 6 cm from the

skin surface with this approach If the advancing attempt does

not produce a fl ash of blood in the hub of the needle, applying

slow continuous negative pressure while withdrawing the needle

potentiates identifi cation of venous blood, thus identifying the

vein However, the absence of pulsatile blood fl ow does not

nec-essarily ensure venous access has been achieved Ideally, a

pres-sure wave should be transduced to confi rm a venous waveform

[45,47]

In addition to the previously described approaches, tunneled

central venous catheters have also been described using the IJV

versus the SCV The IJV approach was easier to perform with

fewer complications [48] Complications of IJV cannulation

include hematoma, carotid artery puncture, nerve damage, air

embolus, and cardiac tamponade

As previously noted, ultrasound guidance for vessel location is

favored by many physicians Investigations utilizing ultrasound

guidance for access of the IJV provide the most compelling

evi-dence in support of this approach Karakitsos et al [49]

per-formed a prospective randomized trial of 900 subjects, evaluating

cannulation of the IJV using ultrasound guidance versus standard

landmark methods After controlling for multiple factors, real

time ultrasound guided catheter insertion of the IJV was signifi

-cantly associated with reductions in carotid puncture hematoma,

hemothorax, pneumothorax, catheter - related infection, access

time from skin to vein and number of attempts when compared

to standard landmark methods

Figure 10.5 Posterior approach to internal jugular vein cannulation In the

posterior approach the needle is advanced along the underbelly of the SCM