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CVP measurement- III
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Femoral vein cannulation
ANATOMY Femoral vein is a direct continuation of the popliteal vein. ↓ Ascends through the thigh, lying at first on the lateral side of femoral artery, then posterior & then medial to it. Leaves the thigh, passes behind the inguinal ligament to become the External iliac vein. Join its counterpart from the other leg → forms the IVC (anterior & to the rt of L5 vertebrae).
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ANATOMY OF FEMORAL VEIN IN FEMORAL TRIANGLE
TECHNIQUE OF FEMORAL VEIN CANNULATION
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complications Deep vein thrombosis & thrombophlebitis.
Pulmonary embolism. Sepsis. Femoral artery puncture .
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Advantages disadvantages
Relatively simple. High success rate %. Remote from the airway & pleura. Directly compressible. Extremely high late complication rate. Unsuitable for long term cannulation.
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Peripherally inserted central catheters
Alternative to centrally inserted catheters. Venous access obtained through an antecubital vein- basillic or cephalic vein. ANATOMY Basilic vein- ulnar aspect of dorsal venous network of hand. ↓ Joins brachial vein to form axillary vein. Continues as Subclavian vein.
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BASILIC VEIN CANNULATION
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approach Patient’s arm at his/her side.
Antecubital fossa- prepared & draped. ↓ Tourniquet placed proximally. Venepuncture- proximal to antecubital crease. Free back flow of venous blood Tourniquet released & guidewire threaded (15-20 cms).
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↓ Needle withdrawn & guidewire left in place. Thread sheath-introducer assembly over guidewire. Remove the guidewire. Secure the catheter. Rt basilic vein -52 cms. Lt basilic vein – 56 cms.
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complications Thrombophlebitis. Limb edema. Hematoma at the puncture site. Infection.
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Advantages disadvantages
Not suitable for long term placement. Thrombophlebitis. Passageinto SVC difficult. Simplicity. Low complication rate Safe placement by non-physicians.
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complications 1. Vascular injury Arterial Venous Hemothorax
Cardiac tamponade 2. Respiratory compromise Airway compression from hematoma. Tracheal, laryngeal injury Pneumothorax 3. Nerve injury 4. Arrhythmias 5. Thromboembolic Venous thrombosis Pulmonary embolism Arterial thrombosis & embolism (air, clot) Catheter or guidewire embolism
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Complications contd…. 6. Infectious Insertion site infection
Catheter infection Bloodstream infection Endocarditis
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Complication Comment 1. Infection rate Femoral – proximity to groin and genital region Subclavian – away from mouth, tracheostomy Infection at site of insertion – absolute C/I 2. Thrombosis & embolisation Femoral vein> subclavian vein> IJV. IJV cannulation - Carotid artery puncture → artherosclerotic embolus to brain.( deadliest complication ) 3. Vein stenosis Catheter infection, mechanical stress
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Complication Comment 4. Bleeding
Arterial puncture- femoral vein> IJV> subclavian Subclavian arterial puncture - hemothorax. IJV cannulation- airway obstruction. 5. Pneumothorax subclavian vein > IJV.
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Cvp waveform CVP waveform consists of- Five phasic events Three peaks ( a, c, v ) Two decents ( x, y )
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NORMAL CVP WAVEFORM Waveform component Phase of cardiac cycle
Mechanical event a wave End diastole Atrial contraction c wave Early systole Isovolumetric contraction, tricuspid motion towards rt. atrium v wave Late systole Systolic filling of the atrium h wave Mid to late diastole Diastolic plateau x decent Mid systole Atrial relaxation, descent of the base, systolic collapse y decent Early diastole Early ventricular filling, diastolic collapse
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Abnormal cvp waveforms
Condition characteristics Atrial fibrillation Loss of a wave Prominent c wave Atrioventricular dissociation Cannon a wave Tricuspid regurgitation Tall systolic c-v wave Loss of x decent Tricuspid stenosis Tall a wave Attenuation of y decent Right ventricular ischemia Tall a & v waves Steep x & y decent Pericardial constriction Cardiac tamponade Dominant x decent Attenuated y decent
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Atrial fibrillation- Absence of a wave, prominent c wave, preserved v wave & y decent. Isorhythmic A-V dissociation- Early systolic cannon wave. Ventricular pacing- Systolic cannon waves ( left panel).
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Tricuspid regurgitation-
Tall systolic c-v wave. Loss of x decent. Tricuspid stenosis- Tall a wave. Attenuation of y decent.
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Clinical interpretation of cvp
CVP reading Other features that may be present Diagnosis to consider Treatment Low Rapid pulse Blood pressure normal or low Low urine output Poor capillary refill Hypovolaemia Give fluid challenges* until CVP rises and does not fall back again. If CVP rises and stays up but urine output or blood pressure does not improve consider inotropes Low or normal or high Rapid pulse Signs of infection Pyrexia Vasodilation/constriction Sepsis Ensure adequate circulating volume (as above) and consider inotropes or vasoconstrictors Normal Rapid pulse Low urine output Poor capillary refill Treat as above. Venoconstriction may cause CVP to be normal. Give fluid challenges* and observe effect as above.
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Clinical interpretation of cvp
CVP reading Other features that may be present Diagnosis to consider Treatment High Unilateral breath sounds Assymetrical chest movement Resonant chest with tracheal deviation Rapid pulse Tension pneumothorax Thoracocentesis then intercostal drain Breathlessness Third heart sound Pink frothy sputum Oedema Tender liver Heart failure Oxygen, diuretics, sit up, consider inotropes Very High Rapid pulse Muffled heart sounds Pericardial tamponade Pericardiocentesis and drainage
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Unreliable cvp readings
Problem Effect on CVP Pulmonary embolus High intrathoracic pressure High pulmonary vascular resistance - left sided pressure and function may be normal. A higher than normal CVP may be needed to ensure adequate return of blood to the left side of the heart. Left heart failure Resulting rise in pulmonary venous pressure and right sided heart strain. Initially CVP may be normal but will increase with significant failure. Constrictive pericardial disease Paradoxical rise in CVP on inspiration and fall on expiration (opposite of normal in a spontaneously breathing patient). The absolute level will be higher due to impeded filling of the heart
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Unreliable cvp readings
Problem Effect on CVP Blocked cotton wool at top of manometer Fluid will not move in the tube to give a correct reading Complete heart block 'Cannon waves' on CVP reading the reading will have a strong pulsatile element when the atrium contracts against a closed tricuspid valve sending the pressure wave back into the SVC Tricuspid stenosis/regurgitation Mean CVP will be higher
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summary CVP is the pressure measured at the junction of right atrium & SVC. Most sophisticated method of CVP measurement is caliberated transducer. Most preferred route is IJV or subclavian vein. The possibility of pneumothorax remains upto 24 hrs, so patient should be watched for it. Strict aseptic precautions should be taken care of. CVP catheters are used for fluid administeration , especially in ICU’s. Femoral route , if possible should be avoided.
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references Miller’s Anesthesia. 7th edition. Cardiovascular monitoring. Monitoring in Anaesthesia and Critical Care Medicine. 5th edition. Mcleod’s Clinical Examination. 11th edition. Central Venous Catheters.2nd edition. Update in Anaesthesia. Central Venous Access and Monitoring. Dr. Graham Hocking, Issue 12 (2000) Article 13. Procedures, Techniques, And Minimally Invasive Monitoring in Intensive Care Medicine. 4th edition.
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PULMONARY ARTERY CATHETER
Swanz ganz catheter. Provides measurements of hemodynamic variables. PAC can be placed from any central venous cannulation routes , but right IJV route is the preferred route. PAC catheter- 7-9 fr. Circumference, 110 cm in length, marked at 10 cm interval, 4 internal lumens.
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