Intraindication: Electrocardiography And Pulse AXIS

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CVC General Consideration

INDICATIONS
To give medications to the patient e.g. vasopressors, chemotherapy, antibiotics1
Parentral nutrition (PEN)
Hemodynamic monitoring – e.g. central venous pressure (CVP)
In case of difficult or poor peripheral venous access

CONTRAINDICATION: some of the relative contraindications are
Anatomic distortion at insertion site
Coagulopathy
Already existing intravascular devices

SITES
Internal juglar vein (IJV)
Suvclavian vein ( SCV)
Femoral vein

MONITORING: – Essential monitoring required – electrocardiography (ECG) and Pulse Oximeter (SpO2).

POSITIONING
Aim of positioning during the procedure should be to maximize the diameter of vein and obtain maximum comfort.
Most adequate position is Supine.
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Non pulsatile Pulsatile
Distend with Not distend oValsalva oValsalva oTrendelenburg position oTrendelenburg position
Doppler Doppler oSteadier “hum” oSharp “whoose”
Spectral Spectral oUndulating waveform oSharp upstroke

SHORT AXIS VS LONG AXIS

SHORT AXIS / OUT OF PLANE LONGITUDINAL AXIS / IN PLANE
Transverse visualization of vein Longitudinal visualisation of vein5
Vein - a dark circle Vessel – dark, thick line
Needle - bright dot Entire length of the needle can be seen screen
Place probe 90º to vein, vein appears as cross section 1st identify vein in transverse axis and then rotate the probe 90º
Needle tip /entire length difficult to visualise Needle tip /entire length & J tip guidewire can be visualised
Easier because oSimultaneously can see both vein & artery oCan differentiate between vein and artery by compression Little cumbersome oSimultaneously cannot see both vein & artery oTechnically difficult to maintain centre of vein

PROBE PREPARATION
Apply gel to probe footprint
Place probe into a sterile covering /sleeve
There should be no air between footprint and covering
Secure sterile cover with rubber band

INTERNAL JUGLAR VEIN
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Indications for left IJV : oRight sided prior cannulation oRight sided scarring on cannulation site oRight sided thrombosis / Devices
APPROACHES: There are three approaches for IJV cannulation central, anterior and posterior. Central approach - Commonly used

Position: supine or slight trendeleberg.

Needle
Puncture site is at apex of triangle
Approximately 5 cm above the clavicle
Needle should be directed towards ipsilateral nipple, angle of insertion should be about 30-45º SUBCLAVIAN VEIN

ANATOMICAL LANDMARK
Site of needle insertion is 1 cm inferior to the junction of the middle and medial third of the clavicle at the deltopectoral groove.

Approach
Supraclavicular - is not preferred because of high incidence of pneumothorax
Infraclavicular - is the most common approach.

POSITION
Supine with slight retraction of shoulder
Trendelenberg reduces the chance of occurrence of VAE

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