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• W1983284917 abstract "The insertion of a central venous catheter (CVC) is a common occurrence in hospital practice. In our own Trust, >500 are placed every month. While most are sited without significant complications or difficulty, the potential for morbidity and mortality is well known. The National Institute for Clinical Excellence (NICE) guidelines on the use of ultrasound for insertion of CVCs [1] has provoked considerable debate in the literature and in theatre coffee rooms across the country. An agenda for change has been set that appears likely to exceed most Trusts’ ability to invest in new equipment and training. However, there are many other aspects of clinical practice with CVCs that should also be addressed if complications are truly to be minimised. Some of these are both simple and cheap to address. Much can be done to make CVC insertion safer if individual institutions ensure that trained practitioners are provided with appropriate facilities. The person inserting the CVC should be adequately trained and experienced in the proposed technique. It follows that occasional practitioners should consider whether their activity level is sufficient to maintain the necessary skills [2]. Central venous catheters should be inserted in an appropriate clinical area where full aseptic technique may be observed. There must be provision for monitoring the patient during and after the procedure. A trained assistant is required. Suitable areas include operating theatres, anaesthetic rooms, the theatre recovery area, a Critical Care environment, and procedure rooms in a Department of Radiology. It is important to recognise which patients are likely to present particular difficulties. An experienced operator should manage these cases; particular consideration should be given to the use of ultrasound guidance [3]. Patients likely to be ‘difficult’ include those with short and broad necks, goitre, tumours and other lumps, the obese and those with a history of neck surgery or previous difficulty with CVC insertion. The presence of a previously inserted CVC also represents an increased risk because of possible associated haematoma or venous thrombosis [4]. In both anaesthesia and intensive care practice, the internal jugular vein is the most common point of central venous access. While there may be some element of convenience to a profession used to working from the ‘top end’, there are clearly anatomical advantages over subclavian and femoral placement with both a straight route for the catheter and its placement just short of the right atrium. There are some differences between these sites in relation to their respective complication rates, be they mechanical, infectious or thrombotic. The principle mechanical complications are arterial puncture, haematoma and pneumothorax or haemothorax. The internal jugular vein and the subclavian vein approaches have similar risks. Pneumothorax is more common with the subclavian route and arterial puncture or injury with the internal jugular approach. However, arterial damage following attempted subclavian vein cannulation can be particularly catastrophic, since manual compression of the artery is difficult. Access to the femoral vein has the highest mechanical complication rate, although these are less likely to be life-threatening, and damaged vessels may be more easily compressed. If central venous access is urgently required in a patient who may be coagulopathic, the femoral route offers some significant advantages. Infectious complications are, not surprisingly, more common at the femoral site where proximity to the perineum along with any surgical drains, stomata or abdominal wounds provide an understandable risk of contamination. There is a marginal benefit in respect of infection favouring the subclavian route over the internal jugular route. This probably reflects the latter's position in the beard area of male patients, its greater risk from oral and tracheostomy secretions, and the fact that it is subject to more movement when the patient's head moves. The risk of thrombotic complications has also been shown to be lowest with subclavian cannulation and highest with the femoral route [2]. Where difficulty or failure has been encountered, or urgent access is required, the external jugular vein should not be forgotten. Cannulated under direct vision like any other superficial vein, it provides close proximity to the central circulation and pressure transduction values have been reported as correlating well with central venous pressure [5]. Additionally, a CVC may be passed via the external jugular vein in an attempt to reach the central veins. However, difficulty is often encountered at the point where the vein passes through the deep fascia. There is good evidence, particularly for internal jugular CVC placement, that the use of ultrasound guidance results in fewer mechanical complications and a higher ‘first-pass’ success rate. However, this is in the hands of individuals trained and experienced in the use of ultrasound [6-8]. There are clearly additional visuo-spacial and motor skills to be mastered, since the operator is required to view a screen with a cross-sectional display, while moving his or her hands elsewhere without continuous direct sight. We have evidence from our own (unpublished) audit data of a ‘learning curve’, even among experienced ‘landmark’ practitioners. Initial data in this group suggest that the first five episodes of cannulation under direct vision should be done with the supervision or support of an experienced colleague if this learning curve is to be safely surmounted. For internal jugular CVC insertion in the absence of such training and experience, consideration should be given to simply scanning the neck before inserting the CVC (if an ultrasound machine is available). In nearly 10% of cases, the internal jugular vein is either absent, small, or medial or lateral to its ‘normal’ position [8]. Dominance of the left internal jugular vein is seen in 20% of individuals [9]. It is possible to confirm the presence of an appropriately sized patent vein and adjust one's proposed landmarks where appropriate. Such scanning in advance of insertion may improve the safety of the ‘landmark technique’ in the hands of those not sufficiently experienced to attempt direct visualisation of cannulation with ultrasound. It has been suggested that ultrasound guidance be reserved for more difficult cases – certainly, there is evidence for significant benefit in this group [3]. However, this would deny the majority of patients access to the ‘gold standard’ technique and result in increased morbidity if not mortality. Additionally, only occasionally wheeling out the ultrasound machine would result in fewer teaching opportunities and a decreased ability to maintain skill in its use. We are not aware of any evidence of practitioners experienced in the use of ultrasound guided CVC insertion returning to the ‘landmark’ technique. It has been suggested that the use of ultrasound may lead to deskilling in the ‘landmark’ technique [10]. However, this seems unlikely, since all the skills of the latter are contained within the ultrasound-guided technique. Central venous catheters impregnated with antimicrobial agents are to be preferred in individuals whose lines may be required for three or more days. There is a decreased risk of catheter-related bloodstream infections and an overall treatment cost reduction when the rate of catheter-related bloodstream infection is >2% [11, 12]. Both the literature and common sense support the use of maximum sterile barrier precautions. These consist of scrubbing, a surgical gown, gloves, hat and mask [2]. However, there is evidence to suggest that, in practice, many operators lapse despite awareness of the above [13]. The field should be cleaned with an appropriate solution such as alcoholic chlorhexidine. This has been shown to be superior to povidone iodine preparations [14]. A large, impervious, fenestrated drape with an adhesive margin around the window is ideal. Simply towelling the head and neck can compromise field sterility since the patient's ear or hair may find their way into the operative field. Patients undergoing elective surgery should have their CVC inserted before surgical preparation. The practice of working under a surgical drape in limited space must threaten aseptic technique and may also result in increased mechanical complications. It is important to maximize the size of the internal jugular or subclavian vein to maximise the chances of successful cannulation. To this end, tilting the patient head-down is very effective. This also decreases the chance of introduction of a potentially fatal air embolus. It is important not to compress the vein with excessive palpating pressure or excessive twisting of the neck. The Valsalva manoeuvre may be useful in conscious patients. Direct vision under ultrasound guidance allows synchronisation with spontaneous or mechanical ventilation. During landmark (blind) insertion into the internal jugular vein, a 23G or 21G ‘seeker needle’ will help to locate the vein [15]. This may decrease the number of needle passes with a larger needle. For subsequent definitive cannulation, the smaller cannula-over-the-needle rather than the larger plain needle should be used to access the vein. This has a smaller cutting tip. Subsequent advancement of the cannula (and removal of the needle) provides further evidence of success if venous blood can still be aspirated. Additionally, with the landmark technique, pressure transduction should be used to confirm venous placement wherever possible. The emergence of dark blood under apparently low pressure is not always reliable. Use of the smaller cannula-over-needle facilitates pressure transduction; the larger gauge needle may migrate and damage structures while being handled and should be avoided. Care should be taken not to breach aseptic technique at the time of pressure transduction. In the absence of transduction facilities, an approximation can be achieved by connecting the cannula to fluid-filled tubing that can then be held erect to form a manometer. During passage of the cannula, if air is aspirated from the neck, one may have breached the pleura and lung. A high index of suspicion for pneumothorax is required. There is a significant risk of haemothorax and no further immediate attempts at CVC placement should be made on that side [15]. A hole in a blood vessel would be expected to stop leaking if tamponaded by surrounding tissues. An adjacent hole in the parietal pleura may provide a large sump for continued bleeding. An immediate approach on the opposite side risks bilateral mechanical complications. A deferral or referral to a more experienced practitioner should be considered. A straight course for the guide-wire is ideal and decreases the risks of misdirection of the dilator. However, many practitioners will recall incidents of difficult canulation followed by the observation of a kinked guide wire. With this in mind, swiping the carotid artery medially while cannulating (or even excessive palpation), changes of needle direction within the neck and a perpendicular needle approach are all to be avoided. In all of these instances, when the needle is removed or palpation ceases, the tissues of the neck will return to their natural shape with a risk of kinking the flexible guide-wire. The guide-wire should be easy to advance and withdraw at all times. Slight traction or withdrawal while passing the dilator decreases the chance of misdirection [16]. The dilator should only be passed a few centimetres to the depth of the vein. This has been the subject of a recent UK Medicines and Healthcare Products Regulatory Agency warning [17]. Further passage along the vein may tear the wall or other distal structures. In order to avoid the tip of the CVC entering the right atrium, right-sided internal jugular and subclavian catheters should be passed to no further than 13 cm, or 15 cm on the left side (for adult patients of ‘normal’ size). After three failed attempts to cannulate a central vein, the risk of mechanical complications has been shown to increase six-fold. Following repeated failure, consideration should be given to deferral to a more experienced colleague [2, 3]. In the event of accidental passage of the line itself into an artery, the CVC should be left in situ and help from an appropriately experienced colleague sought. Radiological investigation and vascular surgical intervention may be required [18]. The vogue for using antibiotic ointment around the catheter site has now been abandoned. An increased risk of fungal colonisation along with a propensity to the growth of antibiotic-resistant bacteria has been shown. There has been no proven benefit in decreasing the incidence of catheter-related bloodstream infections [19-21]. It has been suggested that transparent adhesive plastic dressings give an increased catheter-related infection rate over the use of gauze [22]. However, other workers disagree [23]. The use of transparent plastic dressings has become widespread and offers the clear advantages of both ready inspection of the exit site and an ability to wash without contamination. Following any procedure, an ongoing duty to the patient, particularly in relation to iatrogenic complications, should not be forgotten. A chest radiograph at the earliest convenience is mandatory. The person inserting the CVC has the responsibility for checking this. If not reviewed by this individual, the task should be clearly delegated to an adequately trained colleague. When connecting, disconnecting, injecting and aspirating from the CVC, appropriate aseptic technique should be observed from the outset. Three-way taps and hubs should not be left connected to the CVC without a clean cap. Once a cap has been removed, it should be discarded and replaced with a new sterile one [2]. The need for a CVC should be reviewed daily, and it should be removed when no longer required or if risk exceeds benefit. In patients requiring longer-term use of a CVC, there is no evidence to support ‘routine’ changes after a fixed period of time [2]. Although infection risk increases, surveillance of the exit site, clinical signs and use of blood cultures ensure that lines are not replaced needlessly. Line changes ‘over the guide wire’ are nearly always to be avoided. This procedure can only result in any focus of infection within the catheter or at the exit site being spread along the length of new line, both internally and externally. Line changes over the guide wire are acceptable in the case of a new line in which an immediate fault is found, such as a leak resulting from accidental damage or manufacturing error. There will always be cost pressures cited in response to any proposed changes in medical practice. However, much of what has been described above only requires organisational and protocol changes as part of risk management. Strict use of maximum sterile barrier precautions and antimicrobial-impregnated catheters have both been shown to decrease cost through an overall reduction in infection rate [24, 12]. The use of ultrasound guidance for central venous access has also been shown to be cost-effective. Calvert et al. recently reported in this journal that significant savings can be made even with fairly conservative modelling assumptions [25]. They reviewed trials comparing ultrasound-guided CVC insertion to the landmark technique and considered the treatment costs associated with the excess of complications predicted in the ‘landmark’ group. They also costed the delays in successful insertion in terms of lost theatre time. However, the implications for litigation were not considered. It has already been our experience that patients and their relatives, when faced with an iatrogenic mechanical complication of ‘landmark’ CVC insertion, are beginning to ask searching questions. It seems likely that the courts will be increasingly unsympathetic in cases of ‘landmark’ technique complications, when there is such a weight of evidence in favour of ultrasound guidance. In summary, there is much than can be done to decrease the risks associated with CVC placement. Ultrasound guided insertion is an important development currently attracting much attention. However, simple factors such as who operates, and when and where the procedure is performed, and other practical elements, must not be forgotten if we are to minimise the complications associated with this common procedure." @default.
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• W1983284917 title "Toward safer central venous access: ultrasound guidance and sound advice" @default.
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