Tubes in Holes: Vascular and Anatomical Access PDF

Tubes in Holes: Vascular and Anatomical Access Tufts School of Medicine Physician Assistant Program Andrew Medeiros MMSc, PA-C [email protected]  A Brief History 1656: Christopher Wren; Great Britain used an animal bladder attached to a hollowed g...

Tubes in Holes: Vascular and Anatomical Access Tufts School of Medicine Physician Assistant Program Andrew Medeiros MMSc, PA-C [email protected]  A Brief History 1656: Christopher Wren; Great Britain used an animal bladder attached to a hollowed goose quill to inject opium and alcohol into dogs. 1845: Francis Rynd; Ireland Eye dropper w/ spring-loaded trochar attached to a cannula for local treatment of neuralgia. 1855: Alexander Woof; Scotland Credited with creation of glass syringe. Used to inject morphine locally for peripheral neuralgias. 1894: Hermann Wülfing-Lüer; France Manufactured a unique graduated all-glass hypodermic syringe which allowed for accurate injections and rapid leak-free connections. 1907: Hermann Strauss; Great Britain One of the earliest needles which had a rounded plate on the end for gripping during short term medication administration. A Brief History 1929: Werner Forssmann; Germany Surgical resident who intentionally punctured his own antecubital vein, passed a 4-Fr ureteric catheter, and confirmed placement of the tip of the catheter in the right atrium with an X-ray. He was subsequently dismissed from his studies for his “suicidal” behavior. 1940s: André Counard and Dickinson Richards; USA Further studied right heart catheterization as a clinical tool for cardiovascular research. The three were awarded the Nobel Prize in Medicine in 1956 for their role in central venous access, which is an essential tool in modern medicine. Objectives Vascular Catheters Designs, size, flow Central Venous Access CLABSI/noninfectious complications Arterial Access Endotracheal tube/Tracheostomy Thoracostomy tubes Urinary catheters Enteral tubes Syllabus Overview of critical care medicine touching upon its patient population, the providers, and the various settings it occurs in Discuss indications and complications of various forms of vascular access Describe sterile technique and Seldinger/Modified Seldinger technique Discuss indications for various forms of anatomical access and their complications Describe strategies for preventing CLABSI/CAUTI as well as empiric treatment choices Understand how Pleur-evacs work and the various measurements they obtain Understand the indication/contraindication to RSI Discuss enteral feeding, its routes and indications. Discuss Peyers patches and its implications in immunity/nutrition Vascular Catheters Material Polyurethane Silicone Size Gauge: standardized measure of wire thickness originated in Great Britain. Replaced by the metric system in many fields… French Standardized measure of external diameter of a catheter Multiply diameter by 3 = French 4mm x 3 = 12Fr Vascular Catheters Catheter flow Hagen-Poiseuille equation Q = ΔP x (πr⁴/8μL) Flow (Q) through rigid tubes is a function of the inner radius of the tube (r), the length of the tube (L), and the viscosity of the fluid (μ). Larger inner radius = most profound effect on flow Inverse of length: shorter tube = better flow Rapid volume infusion -> large bore, shortest catheter is optimal choice Central Venous Catheters Patients in the ICU setting often need central venous access for various needs and for varying amounts of time. Indications: Inadequate peripheral access Peripherally incompatible treatments TPN, vasopressors, chemotherapy Hemodynamic monitoring Extracorporeal therapies Hemodialysis, plasmapheresis Access for other medical devices Temporary pacing wires, ECMO, IVC filter Classification Duration: Short-term vs mid-term vs long-term Access type: Non-tunneled vs implanted (tunneled vs ports) Insertion point: Peripheral (PICC) vs central (CICC) Location: Internal jugular, subclavian, femoral, brachial Lumens Single, double, triple, quadruple lumen Heparin bound, Antibiotic-coated Implanted Catheters Tunneled: (weeks to months) Catheter traverses a subcutaneous tunnel between the catheterized vein and the skin exit site. Can be placed with a cuff to anchor it in place and limit bacterial entry. Totally implanted (ports): (months to years) Catheter passes from the vein to a subcutaneous infusion port that is placed into a subcutaneous pocket. Advantages: Concealed from view and overlying skin. Cosmetically appealing. Compatible with activities such as bathing or swimming. MRI compatible. Examples: Port-a-Cath, BardPort, PowerPort, Infuse-a-Port, Mediport Typically related with lower rates of CLABSI compared to non-tunneled. Complications Central Line Associated Bacterial Infections (CLABSI) Lab-confirmed BSI, not related to infection at another site, that develops within 48 hours of central line placement.1 Approximately 90% of CRBSIs in the US occur with CVCs, though the role of PIVs is likely underestimated.2 In the US, ICU rate of CLABSI is 0.8 per 1000 central line days, accounting for ~$46,000 per case.1 Patient Risk Factors: Catheter-related Risk Factors Chronic illness Location: Femoral > IJ > Subclavian Bone marrow transplantation Catheter type: non-tunneled vs tunneled Immune deficiency, especially neutropenia Antibiotic-coated Malnutrition Insertion conditions (emergent vs elective, full barrier Total parenteral nutrition administration precautions vs limited) Previous BSI Catheter care Extremes of age Operator skill Loss of skin integrity, as with burns Central Line Associated Bacterial Infections (CLABSI) Etiology: Gram-positive (MC) Coagulase-negative staphylococci 34.1% Enterococci 16% Staphylococcus aureus 9.9% Gram-negative Klebsiella 5.8% Enterobacter 3.9% Pseudomonas 3.1% E.coli 2.7% Acinetobacter 2.2% Candida species (11.8%) and others (10.5%)  CLABSI Common antibiotic-coated catheters include: chlorhexidine-silver sulfadiazine (CHSS)-coated catheters minocycline-rifampin (MR)-coated catheters  Chlorhexidine Effective against Gram-positive bacteria, Gram- negative bacteria and fungi. Bacteriostatic (inhibits growth) and bactericidal (kills), depending on its concentration. Binds and disrupts the cell membrane. Upon application in vitro, chlorhexidine can kill nearly 100% of Gram-positive and Gram-negative bacteria within 30 seconds. Substantivity Topical application allows chlorhexidine to bind surface proteins and have a prolonged mechanism of action, up to 48h, with limited systemic absorption. Tunneled Line Associated Infections Exit site infection: inflammation confined to typically 2cm from the exit site, typically associated with pain and tenderness along the subcutaneous track. Culture-positive exudate at the exit site that may not be seen unless expressed by palpation.  Gram positive MRSA: Vancomycin MSSA/no MRSA: Staphylococcal penicillin (Nafcillin/Oxacillin) or Cephalosporin (Cefazolin) VRE: Daptomycin Empiric Gram Negative Treatment Low vs High probability of Pseudomonas Neutropenia Critical illness Prior colonization Low: Third generation Cephalosporin (Ceftriaxone) High: Beta-lactam (Cefepime) or Carbapenem (Meropenem) +/- Aminoglycoside (Gentamicin)  Fungal Considered in: Femoral catheterization TPN Prolonged administration of broad- spectrum antibiotics Hematologic malignancy Empiric Treatment Solid organ or bone marrow transplant recipients cont. Azole resistance or Non-albicans: Echinocandins (Micafungin) Otherwise -> intravenous Fluconazole Once susceptibilities are back -> narrow/de-escalate -> good antibiotic stewardship to avoid resistance Strategies to prevent CLABSI in acute-care hospitals: 2022 Update GOAL: Update previously established guidelines from 2014 and assist acute-care hospitals in implementing and prioritizing CLABSI prevention efforts. METHOD: Recruited 3 subject-matter experts to lead a panel of representatives from: Society for Healthcare Epidemiology of America (SHEA) Infectious Diseases Society of America (IDSA) Association for Professionals in Infection Control and Epidemiology (APIC) American Hospital Association (AHA) The Joint Commission Centers for Disease Control and Prevention (CDC). PRIMARY ENDPOINT: Prevention of CLABSI  The Essentials: 1. Know why and have help. 2. Clean, clean, clean -> alcohol-based CHG 3. Follow a checklist and use U/S if available. 4. Use maximum sterile barrier (5pts) 5. Clean at least weekly (daily in ICU) or when soiled Catheter Associated Thrombosis Common complication of central venous catheters and are associated with ~10% of DVTs in adults. Risk factors: Malignancy Hypercoagulability Duration and location -> MC in upper extremities Previous venous thrombosis Infection Ultrasound: high sensitivity and specificity Treatment: Anticoagulation Routine removal of the catheter is not recommended, unless it’s not needed. Prophylactic anticoagulation is not generally recommended, even in patients with risk factors. Seldinger Technique  Arterial Cannulation Uses: Continuous blood pressure monitoring Systolic pressure and pulse pressure variation Blood sampling Arterial blood gas Insertion of mechanical circulatory support, TAVR, cardiac catheterization, Mitraclip, etc. Location: Radial (MC) Brachial Axillary Femoral Dorsalis Pedis Ensure collateral flow w/ Modified Allen’s test Arterial Cannulation and ABGs Indications: Contraindications: Acid-base disturbances Abnormal Allen’s test PaO2 / PaCO2 measurements Local infection, thrombus, or distorted Response to therapeutic interventions anatomy insulin in DKA Severe peripheral vascular disease of IVF in hypovolemia the selected site Abnormal hemoglobin levels (eg Active Raynaud syndrome carboxyhemoglobin/methemoglobin) Infusion of thrombolytics Blood samples in emergencies (streptokinase/tPA) Coagulopathy (relative though should be avoided as much as possible) aPTT >100sec, INR >3, PLT yellow Universal 15mm connector AMBU vs ventilator unit Stethoscope and tape  Uses a rapidly acting induction Traditional or DSI requires bag-mask agent and a neuromuscular ventilation and delayed timing between blocking agent (NMBA) to create sedative and NMBA medications optimal intubating conditions. Enables rapid control of the airway in critically ill patients or emergent situations. Rapid Sequence Intubation (RSI) Incorporates medications/techniques to minimize the risk of aspiration. Anticipation of difficult or impossible rescue Contraindication oxygenation and may require awake intubation RSI *Have a cricothyrotomy tray available as backup always* Tracheostomy tubes Should be considered for patient’s without adequate respiratory recovery within 2 weeks of intubation. Indications: Difficulty weaning off mechanical ventilation Patients who cannot protect their airway and who need ventilation and/or secretion control Patients with severe OSA who are refractory to other therapies Patients with severe subglottic stenosis or vocal cord paralysis who are not responsive to conventional therapies. Absolute Contraindications: Cellulitis of the anterior neck absence of a cervical trachea uncontrolled bleeding Evaluation: CT chest non-con may be needed to evaluate for a high aortic arch Chest tubes (thoracostomy tubes) Purpose: Patient’s requiring evacuation of fluid or air from the mediastinum and/or pleural spaces Indication: Pleural effusions, pericardial effusions, post-surgical, pneumothorax, hemothorax, chylothorax, empyema Types: Surgical True chest tubes Stiffer, larger drains. Available as straight and angled. BLAKE silicone drains More flexible, smaller (normally 24Fr) with a blue radio-opaque stripe. Percutaneous Rocket Seldinger Chest Drainage Safety Guard & Ward Procedure Packs Sizes: 12, 16, 18 & 20Fr Wayne Pneumonthorax Catheter Set  Chest Tube Placement Surgical or percutaneous Placed between the mid-anterior axillary line in the 4th-5th intercostal space tracking above the rib so as not to injure the intercostal bundle. 4th intercostal = nipple or inframammary fold Up and over method creates soft tissue flap so there is less risk of air tracking following removal leading to recurrent PTX. Chest Tube Placement Complications: Bleeding Superficial site infection Deep organ space infection (empyema) Dislodgement of the tube Clogging of the tube Re-expansion pulmonary edema Injury to adjacent organs Intraabdominal, intrathoracic, or diaphragm Pleur-Evac Components Drainage connector/cannula Graduated drainage measurements Suction adjustment (cmH2O) Air leak Monitor Orange negative pressure accordion Sampling Port Urinary Catheters Types: External Condom Catheter, PureWick Indwelling Urethral Foley, Coudé, etc. Suprapubic Intermittent  Urinary Catheters Indications: Urinary retention management Hourly urine output in critically ill Bladder distention prevention/UOP monitoring during surgery Management of neurogenic bladder Management of immobilized patients Management of hematuria with clots End of life comfort care Prevention of contamination of wounds Administration of intravesicular therapies Urological procedures Transurethral resection of the prostate (TURP) Absolute Contraindication: Pelvic or urologic trauma  Complications Bacteriuria (MC) Balloon rupture Requires cystoscopy to remove balloon fragments. Bladder fistula Prolonged catheterization can lead to fistulas with the small bowel, large bowel, rectum, or vagina. Bladder/urethral perforation Bladder stone formation Proteus mirabilis – MC External catheter pressure injury Stricture formation CAUTI Bacteriuria Symptomatic: >103 CFU/mL + symptoms/signs Fever, pain, AMS, hypotension, etc. Asymptomatic: >105 CFU/mL without symptoms/signs Culture Ideally from mid-stream urination or specimen from new catheter. Symptomatic coverage Based on specimen and susceptibilities Empiric antiobiotics for hemodynamically unstable Asymptomatic coverage Pregnancy Prior to invasive urologic procedures Enteral tubes Nutrition is of major importance in the critically ill. A variety of pathologies may increase aspiration risk. In these cases, alternate forms of enteral access should be utilized. Types: Indwelling Nasogastric Double lumen Single lumen: Dobhoff/Levin Orogastric tubes Surgical Gastrostomy tube Jejunostomy tube Enteral Tubes Decompression ISO of distal obstruction/ileus (MC) Indications: Enteral nutrition and medication administration Gastric lavage Facial trauma Contraindications: Known esophageal strictures or varices Coagulopathy Always confirm placement on radiography prior to initiating feeds/meds.  Feeding Gastric feeding Easier placement, stable patients, physiologic feeding Disadvantages Reflux and aspiration risk Post-pyloric feeding More difficult placement; my require fiberoptic endoscopy Advantageous in: severe reflux and esophagitis recurrent emesis post-surgery/ trauma gastroduodenal dysmotility patients on paralytics Absolute contraindication in those who have mechanical obstruction.  Peyer’s Patches The gastrointestinal system plays a major role in many areas of our health including, but not limited to: nutrition, mood, and IMMUNITY. Areas of lymphoid tissue located throughout the small bowel and more notably in the distal ileum. Peyer’s patches play a large role in the body’s immunity given how often pathogens come in contact with the GI system. By feeding our patient’s we are supporting our patient’s natural immunity!  Bibliography Mayer J, Greene T, Howell J, Ying J, Rubin MA, Trick WE, Samore MH; CDC Prevention Epicenters Program. Agreement in classifying bloodstream infections among multiple reviewers conducting surveillance. Clin Infect Dis. 2012 Aug;55(3):364-70. doi: 10.1093/cid/cis410. Epub 2012 Apr 26. PMID: 22539665. Buetti N, Marschall J, Drees M, et al. Strategies to prevent central line- associated bloodstream infections in acute-care hospitals: 2022 Update. Infection Control & Hospital Epidemiology. 2022;43(5):553- 569. doi:10.1017/ice.2022.87 Haddadin Y, Annamaraju P, Regunath H. Central Line–Associated Blood Stream Infections. [Updated 2022 Nov 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430891/ Chlorhexidine Facts: Mechanism of Action