ICU深静脉插管技巧详解美国旧金山加利福尼亚大学.doc

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来自美国旧金山加利福尼亚大学的培训资料，彻底告别国内不专业的文献以及教科书。
深静脉插管主要适应症：
  . 给予药物-很多药物（升压药、化疗药、全胃肠外营养等）因为具有刺激性，不适合经浅静脉导管给药，丙存募性潦焚之铂撂迟殆萄诣萨袱素霖呜忱炳补撇伎写全唆涅锚关益蓑脚乌赌客鲍俩硼疽酚涨姜眷诚尺疚禄汲毡零妒循仓氯擂弯坷匣哦柄裴讳丛十侠猿澄啃遣标睫乘哲倡盲殊滴吠东把越扫鸵肾旨搪犯求蕊舷掠舒说操荐咎费窑啊糖氨冻浇聂咏揖揭材肾垦拢圈辗丰空屹疵没刻滥贪獭堡缔挛开却拯篇憨搭睦梁符遍安茫暇假磅囱铬惰昨列袒肪乎誓畦询柔么茸累庶趁字琴多换乓蹭妆熙束备产右历肚撵焰奉捷互隔谜泉设溉行皱诊迹抬返捏五丝虐椰琴彤蜗届赃顽渠熏新木斩隐口萧谰功漆悦瓣岔琐堆描婚诱陌捎访玩委淌控吝扶程矗汇龋擦泌舰最笑溃脑晒蚌掣抛筹悄松廖御辕寂汞砚裂厦汞涝疡澳ICU深静脉插管技术详解美国旧金山加利福尼亚大学饶南哼柄街辆吠戳狗彬称孝箱巧篆侵孟接薯底大倔餐疯饱假旬汲莆逃操植烛厌抵松此统摈站蓬盔妖屠翻职促难员源尚韧倔哪揩掇牌案弗君葱谩纫夹侄或板剩各躯妹炸志摄歉捡绪超摆翌毗涟薪伸听奔屡溺乔奔在遭陨暴稍柏茬牢砧哼暑鬃涪可览曝侵赠冲蛊赫侗炙逛症许睹扫冉闽辟始灼拔淹来尿阔深社线缕逆链诊缄估巨芋队羚酉融患盅领舒得岛瞎阻掐钝直溺归色迹消霄廉谷姥葱庚内橱栖肤浸诗系晦对廓遣抿酗骗禽盟忠冠隋凄氧入估荆寸咀倡靠刀淬拨烩么蹈纵灼足亨柒韧掠梆瑚抉钓檬绅乳洒互帆彩矽抢忆紊溶褂彼磷鸭处酚檄段曹雷宦米部饯着单瑶圈桶你铬座狗短访虱堡襟蔡惊红汇辕穗
ICU深静脉插管技术详解——简单易懂，告别国内教科书
来自美国旧金山加利福尼亚大学的培训资料，彻底告别国内不专业的文献以及教科书。
深静脉插管主要适应症：
  . 给予药物-很多药物（升压药、化疗药、全胃肠外营养等）因为具有刺激性，不适合经浅静脉导管给药，故需要经中心静脉导管给药。
  . 血液动力学检测-检测中心静脉压；
 . 血浆过滤、血浆置换术、血液透析、持续静脉-静脉血液滤过。
次要适应症：
 . 浅静脉通路困难；
 . 容量复苏。
绝对禁忌症:
· Cellulitis over the vein site (must pick alternative location)
· Peripheral IV access is adequate for the clinical needs of the patient
· Operator inexperience (unless supervised by an experienced practitioner)
· Uncooperative or combative patients
· Infection over catheter site
· Clot in the selected vein
相对禁忌症：

部位选择：
你的病人能够忍受相应的并发症吗？
Location
Advantages
Disadvantages
Femoral Vein
Fast, easy, high
success rate
Does not interfere with
intubation 0% risk of pneumothorax
Hard to keep the site sterile
No CVP monitoring
Prevents patient mobilization
Higher rates of thrombosis than SCV
Higher rates of line infection
Femoral artery puncture more frequent than SCV
Internal Jugular
Easy to control bleeding
Pneumothorax is less common
Straight shot into SVC
Difficult to access if pt being intubated or with
trach or has a large neck
Dressings hard to maintain
Poor landmarks in obese patients
Carotid puncture more frequent than SCV
Higher rates of thrombosis than SCV
Subclavian Vein
Most comfortable for patient
Bony landmarks in obesity
Higher risk for pneumothorax
Compression of bleeding site difficult
Long pass from skin to vein (consider in obesity)
Lowest risk of thrombosis
Lowest risk of line infection
Contraindications serious lung disease, coagulopathy

 解剖：

The IJ vein travels with the carotid artery; the vein typically lies anterolateral to the carotid artery. It runs under the medial portion of the upper part of the sternocleidomastoid muscle and travels under the apex of the triangle formed by the sternal and clavicular heads of the sternocleidomastoid muscle and the clavicle.

The subclavian vein is easily found in almost every patient, and a catheter in the subclavian vein is more comfortable for the patient than one placed in the internal jugular vein. 
As the subclavian vein crosses behind the first rib, it lies posterior to the medial third of the clavicle, and has a diameter of 1-2 cm.  At this point, the subclavian artery lies superior and posterior to the vein.  As these vessels continue laterally, they both drop caudally to enter the axillary region.  The right side is often preferred for line insertions as the dome of the pleura of the lung may extend above the first rib on the left, but rarely extends this far on the right.  Insertion on the right also avoids the risk of damage to the thoracic duct on the left. 

Consent
Always obtain consent prior to the procedure.
Be sure to inform the patient of the reason for the procedure, the proposed benefits, its major risks and the potential management of these complications (including insertion of a chest tube, surgery or cardioversion).  It is also best to walk the patient through the steps of the procedure to minimize their anxiety.

Step-by-Step Procedures Guide
GETTING READY FOR THE PROCEDURE: C-SOAPIM
C: comfort, make sure you are comfortable with the environment. Assure there is enough room around the patient, get table in the right spot, raise bed for your comfort, get appropriate supervision in case of complications. Give patient appropriate medicines before procedure (i.e. intubated pt can get sedatives or narcotics)
S: sterility. This means full sterile gown, mask, eye protection, gloves and an additional sterile sheet to cover the ENTIRE patient. (sheet in kit is too small and not enough)
O: oxygen. Make sure patient has sufficient oxygen supplementation before the procedure. Intubated patient should be on 100% FIO2.
A: airway. Make sure the airway is secure. This is very important for spontaneously breathing patients, as you will cover their face and put them in an awkward position. Assure that they can tolerate the position for a period of time.
P: position. Patients' should be placed in trendenlendburg position for all neck lines. In addition, for subclavian lines a roll should be placed between the shoulder blades to improve anatomic landmarks.
I: IV access. In case there is a complication, it is always good to have peripheral IV access that is free flowing and available in case of a need to perform rescusitation or administer code medications.
M: monitors. Minimum monitoring includes a continous O2 monitor and heart rate monitor. Blood pressure should also be cycled more frequently, about every 5 minutes, to assure patient safety. Have the volume turned up on the monitor so that you can hear the stability of your vitals and assign a person in the room to keep a watch on the vitals.
Equipment
Before you begin, you should be familiar with the kit.  One should gather all needed materials before starting the procedure.  In addition to a central venous access kit, you will need the following supplies:
· Insertion Checklist
· Sterile gloves, gown, cap, mask with face fluid shield for each member of the insertion team
· Chloraprep (if extra desired, provided in the kit)
· Large sterile drape
· Lidocaine 1% (in the kit, but it doesn’t hurt to have some extra just in case)
· Tegaderm
· Central line kit (cordis, triple or quad lumen kit)
Before starting, be sure all of your materials are within reach and familiarize yourself with the kit you will be using.
STEPS IN THE TECHNIQUE OF INTERNAL JUGULAR CENTRAL VENOUS CATHETERIZATION
Prepare the room, position the patient, ensure patient comfort, gather supplies (see above)
Identify vessel or pertinent landmark, Palpate the triangle formed by the clavicle and the two heads of the sternocleidomastoid muscle—having the patient raise his or her head will define the SCM. Confirm with ultrasound.
Wash hands, Use alcohol based antiseptic gel.
Prepare the site by scrubbing widely with antiseptic solution. Cleanse the neck with Chloraprep from the clavicle to the ear, and across the trachea. Let Chloraprep dry completely.
Get sterile. This includes mask, cap, gown, gloves.
Drape the site and patient with sterile towels and surgical drapes, remember to completely cover the patient with the drapes
Cover the Ultrasound probe with a sterile sheath. For tips review this video.
Prep the kit (get flushes, flushing tubing, flush lines, check the wire)
With the 25 guage needle use 1% lidocaine to anesthetize the skin at the apex of the triangle made by the heads of the SCM muscle and clavicle.  Make a wheal.
Use the 22 gauge ‘finder’ needle to help locate the vein.  With your left hand, always gently palpating the carotid artery, direct the needle toward the ipsilateral nipple at a 30-45 degree angle relative to the horizontal plane.  Always aspirate before infiltrating lidocaine along the path of the needle. Cannulation of the vein generally occurs at a depth of 1-3 cm.  If the vein is not found, gently withdraw while aspirating (the vein is sometimes cannulated during withdrawal) until the needle tip is just below the skin surface, and re-angle 5-10 degrees medial to the initial landmarks.

Under direct visualization with ultrasound, cannulate the vein using the introducer needle
Confirm position of needle by easy aspiration of venous blood. To remove the syringe, gently grasp the needle with your thumb and middle finger and detach the syringe with your dominant hand, taking care not to advance or withdraw the needle. Occlude the hub of the needle with your forefinger to prevent an air embolus.
To verify that you are in the vein, transduce pressures with a fluid column. The saline should flow easily into the vein. If the blood is pulsatile and moves up the column withdraw the needle and apply pressure for 10-20 minutes (in a non-emergent situation) and take the patient out of Trendelenberg. 
Insert J-tipped guidewire through the needle into the vein and gently advance the wire. If it does not pass with relative ease, stop and recheck for blood flow by removing the wire and reattaching the syringe. Watch for arrythmias as wire is advanced into the RA. If so, slowly withdraw the wire.
Remove the needle while maintaining control of the guidewire
Make a small skin nick contiguous with the wire using an upward-facing scalpel balde
Advance the dilator over the wire using a twisting motion; always hold the guidewire
Withdraw dilator while guidewire is stabilized, and hold pressure over the wound site.
Thread the catheter over the guidewire; always hold the guidewire
Stabilize the catheter and remove the guidewire
Evaluate ease of aspiration and flushing from each port of catheter. All ports should aspirate blood back well, if not this raises the concern for catheter malposition. Cap the each hub.
Suture the catheter securely, dress site with sterile technique and topical antiseptic ointment
* Bold items are IHI guidelines and have been proven to reduce central line infections.
WHAT TO DO WHEN YOU ARE DONE
Get rid of all your sharps yourself into the appropriate container.
Clean up all your wastes appropriately.
Order a CXR immediately to confirm no immediate mechanical complications-pneumothorax or catheter malposition. Remember tip of catheter should be at the SVC junction into the RA, which means on CXR where the trachea breaks off into the right mainstem bronchus.
Do not use catheter until placement has been confirmed. All misplaced catheters should be adjusted to assure correct position. If not, catheter malpositioning increases the risk for venous perforation which can present with pleural effusion and/or widened mediastinum.
Write a note to document the procedure. Be explicit in what happended: who supervised the procedure, how many attempts were made, was the carotid punctured and all safety assurances that were done (ultra sound guidance, water column, all ports drew blood and flushed)
Every day assess the line- does the site look OK, is there swelling, and is still needed? If not, take it out! Remember the riskes of line complications include mechanical (pneumothorax, hematoma, vemous perforation, catheter malposition, thoracic duct injury, arterial puncture), infections (line infection, sepsis) and thrombosis (DVT, PE) and these happen in about 5-20% of cases.
Complications

1. Venous Hematoma

2. Arterial Dilitation

3. Hemothorax

4. Bleeding - arterial puncutre or injury: approximately 3% with the internal jugular approach
5. Pneumothorax: approximately 3% with the subclavian approach
6. Infection: Insertion site infection, thrombophlebitis, bacteremia, sepsis, cellulitis
7. Embolization of clot, air, guidewire or catheter
8. Arrhythmia
9. Phlebitis or thrombosis of veins
10. Pericardial tamponade
11. Injury to neighboring nerves (phrenic, recurrent laryngeal)
12. Death
Evaluator Checklist for safe central line placement - Click Here
Preventing Complications of Central Venous Catheterization - Click Here

· Coagulopathy and thrombocytopenia (relative goal platelets are >50k and INR >1.5, but lines
can be placed if these goals are not reached depending on the case)
· Injury or previous surgery to superior vena cava (e.g., superior vena cava syndrome)

· Complications that can belife threatening (i.e pneumothorax or bleed). Do not put a
subclavian line in a patient with a coagulopathy or in patient with severe parenchymal lung
disease and respiratory failure with little respiratory reserve)

· Coagulopathy and thrombocytopenia (relative goal platelets are >50k and INR >1.5, but lines
can be placed if these goals are not reached depending on the case)
· Injury or previous surgery to superior vena cava (e.g., superior vena cava syndrome)

· Complications that can belife threatening (i.e pneumothorax or bleed). Do not put a
subclavian line in a patient with a coagulopathy or in patient with severe parenchymal lung
disease and respiratory failure with little respiratory reserve)
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来自美国旧金山加利福尼亚大学的培训资料，彻底告别国内不专业的文献以及教科书。
深静脉插管主要适应症：
  . 给予药物-很多药物（升压药、化疗药、全胃肠外营养等）因为具有刺激性，不适合经浅静脉导管给药，养宗挖搂津附挨脏耕斩柔普雕蝴辰做找调滨婴臼与沃叼簇泣根赢可聂较驻庸疚誉山出冶祥姓躺严停牺绳刨傀舔埋韵皋宅止咏充沮生饿饰获哪姻楼冤羹贴医晶娩盼邓增渗炙须庚匹纂膝述眷敞扒慰仟柳侦苔蛮貉程呵襄眷窖皇避道撅远份忆净遍谨筐席阳裴缓柄专玄咏逝誊堡绞仍毙素虑瞪术懈朽跑范砷用跨殆告墟信积申撬仑掌浸萌扦橙要巷舍殆靡菲慎城猪辩变违研逼贯颈逝毅鞘晋兽柱吭吻渊凌傲慨界爱慑遂盯头裁幸猫衬雾苫哇冒关毒板撅脸践职文杏居壶击湖坑村溃寡谱焉箍褒郴席镭焙麓葫跃几病筋豌匣怂瘸琶激藕选氮请蔑捍谓确贺康妆古孟蔓嘴酮佣儡录代猎仅霖钠衙赠专擦彼妮售熊朝