1. Central Venous Access

2. Indications Peripheral access impossible. Administration of irritant medications inc. TPN. Measurement of mixed venous oxygen saturations. Right heart catheterisation. RRT / ECMO etc. NB - NOT fluid status

3. Assessment What aspects of the patient examination and investigations need to be taken into account before inserting a central line?

5. Monitoring and Environment Where should a central line be inserted? What monitoring is required?

6. Infection Control

7. Site What sites are available for central access? What are the advantages / disadvantages of each?

8. Internal Jugular

9. External Jugular

10. Subclavian Femoral PICC

11. Ultrasound Position the ultrasound screen on the other side of the patient to allow easy viewing Touch the side of the probe while observing the image to orientate the probe. (Some probes have a mark that corresponds to one side of the screen for this purpose) Alter the gain to produce a relatively dark image that will help discriminate the white of the needle tip Use sterile gel inside the probe sheath (and between the sheath and the patient’s skin) to provide acoustic coupling Throughout the procedure, maintain a sterile environment. (The operator should be wearing a sterile gown, mask, hat and the area should be cleaned before drapes are applied)

12. Short vs Long Axis View

13. How can you differentiate between vein and artery?

14. Veins are (usually)…. Where you expect then to be Compressible Non-pulsatile Varying in size with respiration, valsalva, fluid loading

15. Seldinger Technique

16. Complications What complications are related to insertion of the line (immediate complications)?

17. Arrhythmias Venous bleeding Arterial bleeding Pneumothorax Cardiac perforation Embolisation (air or thrombus) Retained wire

18. What adjacent structures can be damaged when attempting IJV cannulation?

19. Thoracic duct Vagus nerve Brachial plexus Phrenic nerve Stellate Ganglion Glossopharyngeal nerve

20. What are the potential delayed complications?

21. Sepsis Extravasation (dislodgement) Thrombosis

22. CXR Position Good PositionAbutting SVC