CE NT RAL L INE PL ACE ME NT IN T HE ICU E mily Hurst, - PowerPoint PPT Presentation

CE NT RAL L INE PL ACE ME NT IN T HE ICU E mily Hurst, DO, F ACOI Critic a l Ca re Me dic ine Ave ra e I CU Me dic a l Dire c to r

OBJE CT IVE S 1) Re vie w I ndic a tio ns a nd Me dic a tio ns Ne c e ssita ting Ce ntra l L ine Pla c e me nt 2) I nc re a se Awa re ne ss o f Alte rna tive Me tho ds to Ce ntra l L ine Pla c e me nt T hro ug h Disc ussio n a nd Ca se Pre se nta tio n 3) Pro vide Re so urc e s a nd Optio ns fo r U niq ue Circ umsta nc e s Whe n Ce ntra l L ine Pla c e me nt Ma y No t Be Appro pria te

WHY T HIS L E CT URE ? • I CU Pa tie nts Ne e d Ce ntra l Ac c e ss – o r do the y ? • Pa tie nt Sa fe ty a nd Co mfo rt • Sta ff Co nstra ints • Ac c e ss to Ca re • Me dic a l Co sts • Me dic a l Wa ste

ME DICAT IONS NE E DING CE NT RAL ACCE SS F OR ADMINIST RAT ION • Va so pre sso rs • Che mo the ra pe utic Ag e nts • 3% NS • T PN • Ha ve a pH < 5 o r > 9 • Do butam ine (3.5) • Dilantin (12) • T o bram yc in (3) • Ve no us I rrita nts • Am pho te ric in B

WHICH BE COME S AN E ME RGE NCY? ? Vaso pre sso rs

CE NT RAL L INE OPT IONS • Do uble L ume n Ce ntral Cathe te r • T L C (T riple L ume n Ce ntral Cathe te r) • Co rd is • Mid line • Me d ipo rt • PICC (Pe riphe rally Inse rte d Ce ntral Cathe te r) • T unne le d Ce ntral Cathe te r

CL CONT RAINDICAT IONS AND COMPL ICAT IONS • Infe c tio ns • Ce ntra l L ine Asso c ia te d Blo o dstre a m I nfe c tio ns (CL ABSI ) • L o c a lize d Ce llulitis • Ble e d ing • E xc e ssive Blo o d L o ss • Co ag uo pathic • I a tro g e nic a lly E le va te d I NR • L ive r F a ilure • Blo o d Clo tting Diso rde r • Pne umo tho rax/ He mo tho rax • VT E (Ve no us T hro mbo e mbo lism) • Co mpartme nt Synd ro me (IO)

E ME RGE NT T L C AL T E RNAT IVE S • Ce ntral • Me d ipo rt • IO (Intra Osse o us) • Mid L ine • PICC (Pe riphe rally Inse rte d Ce ntral Cathe te r) • Pe riphe ral • PIV (Pe riphe ral Intrave no us) • SQ Butto n (Subc utane o us) • SL (Sub-L ing ual)

CONT RAINDICAT IONS T O AL T E RNAT IVE S Big g e st Co mp lic a tio ns: Ca n’ t p la c e !!! E xtra va sa tio n

CL CONT RAINDICAT IONS AND COMPL ICAT IONS • Infe c tio ns • Ce ntra l L ine Asso c ia te d Blo o dstre a m I nfe c tio ns (CL ABSI ) • L o c a lize d Ce llulitis • Ble e d ing • E xc e ssive Blo o d L o ss • Co ag uo pathic • I a tro g e nic a lly E le va te d I NR • L ive r F a ilure • Blo o d Clo tting Diso rde r • Pne umo tho rax/ He mo tho rax • VT E (Ve no us T hro mbo e mbo lism) • Co mpartme nt Synd ro me (IO)

CONT RAINDICAT IONS T O AL T E RNAT IVE S Big g e st Co mp lic a tio ns: Ca n’ t p la c e !!! E xtra va sa tio n

VASOPRE SSORS • No re pine phrine (L e vo phe d ) • Do pamine (Ino tro pin) • Vaso pre ssin (Pitre ssin) • Phe nyle phrine (Ne o -Syne phrine ) • E pine phrine (Ad re naline ) • Do butamine (Do butre x)

NORE PINE PHRINE (L E VOPHE D) • Alpha-1 Ad re ne rg ic • 2-100 mc g / min (0.5-3 mc g / kg / min) • Pre sso r o f Cho ic e in MOST Sho c k • Se ptic • Card io g e nic • Hypo vo le mic • I njury With E xtra va sa tio n I njurie s > 33 mc g / min • 10 mc g / min T hro ug h a PI V

DOPAMINE (INOT ROPIN) • Alpha-1Ad re ne rg ic • 2-20 mc g / kg / min • Se c o nd -line Ag e nt to No re pine phrine • Adve rse E ffe c ts: T a c hya rrhythmia s • JUST as Dang e ro us as No re pine phrine !!! • “Re nal Pro te c tive ” Do se s – Out the Windo w • 2-5 mc g /kg /min With PI V

VASOPRE SSIN (PIT RE SSIN) • Antid iure tic Ho rmo ne • 0.04 Units/ Minute (No t T itrate d ) • Aug me nts Othe r Pre sso rs • Pure Vaso c o nstric to r • MAY De c re ase Stro ke Vo lume and Card iac Output • Re c e nt Stud ie s No t Suppo rtive

PHE NYL E PHRI NE (NE O-SYNE PHRINE ) • PURE Alpha-Ad re ne rg ic Vaso c o nstric to r • 20-200 mc g / minute (0.25 -2.4 mc g / kg / min) • Initial Vaso pre sso r fo r T ac hyarrhythmias • No Kno wn E xtravasatio n Issue s • Arg ua b ly Sa fe st o f All Pre sso rs Pe riphe ra lly • T hro ug h a PI V 10-20 mc g / min

E PINE PHRI NE (ADRE NAL IN) • Alpha-1 Ad re ne rg ic • 1-35 mc g / min (0.014-0.5 mc g / kg / min) • Initial Pre sso r fo r Anaphylac tic Sho c k • Usually Se c o nd ary Ad d e d Ag e nt • Ad ve rse E ffe c ts • Inc re ase s He art Rate –T ac hyarrhythmias • E le vate d L ac tate • De c re ase d Me se nte ric Pe rfusio n

DOBUT AMINE (DOBUT RE X) • Be ta-1 Ad re ne rg ic • 0.5-20 mc g / kg / min • Ag e nt o f Cho ic e in Card io g e nic Sho c k IF: L o w Card iac Output (WIT H Maintaine d BP) • Ad ve rse E ffe c ts: • Hypo te nsio n • T ac hyarrhythmias

ST AGE S OF E XT RAVASAT ION INJURY Sta g e 1 : Painful Site , No E rythe ma o r Swe lling , Flushe s with Diffic ulty Sta g e 2 : Painful Site , Slig ht Swe lling & E rythe ma, No Blanc hing , Brisk Cap Re fill Be lo w Site Sta g e 3 : Painful Site , Marke d Swe lling & Blanc hing , Co o l to T o uc h, Brisk Cap Re fill Be lo w Site Sta g e 4 : Painful Site , Ve ry Marke d Swe lling & Blanc hing , Co o l to T o uc h, Capillary Re fill > 4 Se c o nd s, De c re ase d o r Abse nt Pulse , Skin Bre akd o wn o r Ne c ro sis

E XT RAVASAT ION T RE AT ME NT 1) CHANGE Site s • Switc h to ano the r IV • Plac e IO o r c e ntral line 2) DO NOT Re mo ve Cannula 3) E XT RACT / ASPIRAT E as Muc h SQ Fluid as Po ssible 4) T RE AT with Phe nto lamine ( Se e Ne xt Slide ) 5) CONSUL T Plastic s

PHE NT OL AMINE ADMINIST RAT ION • Vials o f 5 mg / 1 ml • Plac e in 9 ml o f NS • Do se : 0.1 to 0.2 mg / kg (Max 10 mg ) • Use 25 G Ne e d le (o r Smalle r) • Inje c t T hro ug h Cathe te r • SQ Aro und the Site

PHE NT OL AMINE ADMINIST RAT ION • Ad ministe re d ASAP • E ve n if Are a L o o ks a L ittle White o r OK • E ffe c ts Sho uld be Imme d iate • May Ne e d to Co nsid e r Ad d itio nal Do se • No w Pull the Cathe te r

HOW PE NT OL AMINE WORKS • Alpha1-Blo c ke r • Diminishe d Vaso c o nstric ting E ffe c t • Ad ve rse E ffe c ts • Syste mic Hypo te nsio n • Ce re b ro va sc ula r Spa sm • T ac hyc ard ia/ Card iac Arrhythmias

HYAL URONIDASE F L USHING • Cre a te Dilute Hya luro nidase • Ra tio : 150 units/ ml o f Sa line • Do se is 1ml (Ma x 2 ml) • Use 25 G Ne e dle (o r Sma lle r) • Numb Are a with L ido c a ine ( Witho ut Epi ) • I nje c t 5 Se pa ra te Are a s Aro und E dg e s o f E xtra va sa tio n • I nje c t T hro ug h Orig ina l Ca nnula ( if No t Ye t Re mo ve d )

HYAL URONIDASE F L USHING • Ma ke 4 Sta b Wo unds Aro und E a c h Po int • I nse rt a Ca nnula • Blunt E nde d With Side Ho le s (L io psuc tio n Ca nnula ) F lush 500 ml o f NS T hro ug h the Wo und • • Ho w it Wo rks: • Re ve rsib ly Hydro lyse s Muc o po lysa c c ha ride s o f SQ T issue s • E nha nc e s the Pe rme a b ility o f T issue Co mpa rtme nt • I nc re a se d I rrig a tio n

E XT RAVASAT ION PRE VE NT ION GUIDE L I NE S • Avo id the Ha nd a nd Wrist • Ca utio n in the AC F o ssa • Avo id Po o r Qua lity/ Que stio nab le I Vs • Co nside r Avo iding U S Guide d L ine s • Pe rfo rm a n E xtre mity Che c k Pe r Pro to c o l E ACH T I ME • Ha ve Antido te s Re a dily Ava ila b le • Phe nto la mine Additive s • 10 mg / L ite r o f So lutio n • Do e s NOT Dilute Pre sso r E ffe c t

CASE PRE SE NT AT ION # 1 • 53 yo Fe ma le With Sc le ro de rma o n Che mo the ra pe utic Ag e nt Cyto xa n. Pre se nts with R) L L Pne umo nia , Se psis a nd I ntra c ta b le N/ V. • BP is 82/ 44, HR 118 • Me nta tio n Diminishe d, b ut Answe ring Que stio ns • Una b le to Ma inta in PI V (Ha d T wo ) • On Va nc o , Zo syn • Blo o d Gluc o se 473

CASE # 1 DISCUSSI ON • Do e s T his Pa tient Ne e d a Ce ntra l L ine ? • Wha t Wo uld Yo u T ry F irst? • Wha t is She Go ing to Ne e d? • Wha t if BP Re spo nds to a 500 c c F luid Bo lus x 1 • Ho w L o ng Ha s She Ha d Na use a a nd Vo miting ?

CASE # 1 DISCUSSI ON • Do e s T his Pa tient Ne e d a Ce ntra l L ine ? • Wha t Wo uld Yo u T ry F irst? • Wha t is She Go ing to Ne e d? • Wha t if BP Re spo nds to a 500 c c F luid Bo lus x 1 • Ho w L o ng Ha s She Ha d Na use a a nd Vo miting ? • Wo uld T his b e Cha ng e d if Blo o d Gluc o se wa s 47?

CASE # 1 DISCUSSI ON • Do e s T his Pa tient Ne e d a Ce ntra l L ine ? • Wha t Wo uld Yo u T ry F irst? • Wha t is She Go ing to Ne e d? • Wha t if BP Re spo nds to a 500 c c F luid Bo lus x 1 • Ho w L o ng Ha s She Ha d Na use a a nd Vo miting ? • Wo uld T his b e Cha ng e d if Blo o d Gluc o se wa s 47? • Ho w Do e s She Re c e ive He r Cyto xa n?

CASE PRE SE NT AT ION # 2 • 32 yo Ma le with E SL D Se c o nda ry to E T OH. On Mido drine 5 mg T I D with a BP o f 88/ 34 – MAP o f 52 • Me nta tio n is De c re a se d, b ut Appro pria te a nd Sta b le • Cr is 4.2 • ME L D Sc o re is 36 • L a st E T OH wa s 5 Mo nths Ag o