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  • 8/7/2019 The Ten Surgical Procedures


    The Ten Surgical Procedures

    Submitted By:

    Jayzel & Marjay

    Submitted To:

    The Nutty Professor

    Submitted On:

    May 19, 2010

    Year & Section:


    Central Venous Pressure Monitoring

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    Central venous pressure is considered a direct measurement of the blood pressure in

    the right atrium and vena cava. It is acquired by threading a central venous catheter

    (subclavian double lumen central line shown) into any of several large veins. It is

    threaded so that the tip of the catheter rests in the lower third of the superior vena cava.

    The pressure monitoring assembly is attached to the distal port of a multilumen central

    vein catheter.

    Assisting with CVP placement

    y Adhere to institutional Policy and Procedure.y Obtain history and assess the patient.y Explain the procedure to the patient, include:

    o local anesthetico trendelenberg positioningo drapingo limit movemento need to maintain sterile field.o post procedure chest X-ray

    y Obtain a sterile, flushed and pressurized transducer assemblyy Obtain the catheter size, style and length ordered.y Obtain supplies:

    o Maskso Sterile gloveso Line insertion kito Heparin flush per policy

    y Position patient supine on bed capable of trendelenberg positiony Prepare for post procedure chest X-ray

    The CVP catheter is an important tool used to assess right ventricular function andsystemic fluid status.

    y Normal CVP is 2-6 mm Hg.y CVP is elevated by :

    o overhydration which increases venous returno heart failure or PA stenosis which limit venous outflow and lead to venous

    congestiono positive pressure breathing, straining,

    y CVP decreases with:o hypovolemic shock from hemorrhage, fluid shift, dehydrationo negative pressure breathing which occurs when the patient demonstrates

    retractions or mechanical negative pressure which is sometimes used forhigh spinal cord injuries.

    The CVP catheter is also an important treatment tool which allows for:

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    y Rapid infusiony Infusion of hypertonic solutions and medications that could damage veinsy Serial venous blood assessment

    Venous Cutdown and Intraosseous Infusion

    Gaining intravenous access is a common procedure but may be difficult inhypovolaemic patients or those with difficult veins. When direct cannulation of a veincannot be performed or is taking too long, a venous cutdown or intraosseous infusionare alternative methods of access to the circulation. These two techniques aredescribed below. In this article "proximal" means the part of the vein or bone closer tothe chest, and the word "distal" the part of the vein or bone furthest from the chest.

    Venous cutdown

    This procedure exposes the vein surgically and then a cannula is inserted into the veinunder direct vision. If no cannulae are available the sterile end of the drip tubing may beused in adults after cutting off the Luer (cannula) connection. The procedure must beperformed under sterile conditions to avoid sepsis developing which will not onlyshorten the life of the infusion but may have serious consequences for the patient.

    During the procedure 2 ligatures (sutures) are placed around the vein. The distalligature is used to tie off the vein distally and the proximal ligature holds the cannula inthe vein While the vein is incised the ligatures help to hold it.


    1. Sterile gloves2. Swabs and sterile drapes3. Skin disinfectant4. Local anaesthetic (5ml of 0.5% lignocaine is sufficient)5. Scalpel6. Two small curved artery forceps7. Sharp pointed scissors (use scalpel if scissors blunt/unavailable)8. Ligatures (2/0 catgut / vicryl are best, but silk is adequate)

    9. Skin closing sutures10. Cannula

    Sites. In adults use the upper limb at the medial aspect of the antecubital fossa. Try toavoid the leg veins as they are thicker and more prone to thrombosis, phlebitis andinfection. In children a cutdown may be performed using either the brachial or longsaphenous veins.

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    Technique. Clean the skin and use the drapes to create a sterile area around thechosen vein.

    (1) Infiltrate the skin with local anaesthetic.

    (2) Make a 1.5 - 2cm transverse incision over the vein(a).

    (3) Bluntly dissect out the vein by opening the forcepsin the line of the vein (b).

    (4) Make a small stab skin incision 1cm distal to the incisionin the line of the vein. Pass two ligatures around the vein.Tie the distal one, but leave the ends uncut. Hold the endsof the ligatures with the artery forceps (c).

    (5) Whilst holding the ligatures tight, make a "V" shapedincision in the anterior surface of the vein with the scissorsor scalpel (d).

    (6) Pass the cannula through the inferior stab incision andthe through the "V" shaped incision into the vein. Tie the

    proximal ligature tightly over the cannulated vein and, ifthere is no bleeding, now cut the ends of the ligatures. Ifbleeding occurs place a further ligature around the vein.Connect the cannula to the giving set and commence theinfusion.

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    (7) Close the skin with sutures (f).

    After the infusion is finished the cannula can be removed by a

    firm steady pull followed by direct pressure over the site ofthe incision for 5 minutes.

    Placement of an internal jugular dialysis catheter into the superior intercostal


    (Section Editor: G.H. Neild)

    Mark J. Sarnak and Andrew S. Levey

    Division of Nephrology, New England Medical Center, Boston, MA, USA

    Correspondence and offprint requests to: Mark J. Sarnak, MD, Division of Nephrology,New England Medical Center, Box 391, 750 Washington Street, Boston, MA 02111,USA.

    Keywords: catheter; chest radiograph; haemodialysis; internal jugular vein

    The value of a routine radiograph following an uneventful placement of an internaljugular haemodialysis catheter has been questioned.The argument is that unsuspectedfindings occur in less than1.5% of routine chest radiographs after uneventful placement

    of internal jugular catheters [1]. We describe an unusual venous anomaly that wasrevealed by a routine post-procedure chest radiograph and review the potentialcomplications that may haveresulted if dialysis had been initiated.


    A 79-year-old woman with a history of chronic renal insufficiency was admitted to thehospital after suffering a myocardial infarction. She became progressively fluidoverloaded and required ventilatorysupport. A 16-cm dialysis catheter was placed in theleft internal jugular vein for haemodialysis access. Non-pulsatile dark blood wasaspirated and the haemodialysis catheter was placed without difficulty using theSeldinger technique. No complications weresuspected. A subsequent chest radiograph(Figure 1 ) revealed the tip of the catheter projecting on the lateral aspect of theproximal descending thoracic aorta. An angiogram (Figure 2 ) was performed whichshowed an occluded left brachiocephalicvein. Drainage of the left internal jugular and

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    subclavian systemswas through a superior intercostal vein that communicated withanaccessory hemiazygos vein and subsequently drained into the azygos vein. Theabsence of any relevant medical history suggested that the anomaly was most likelycongenital in origin. The catheterwas removed due to the concern that the caliber of theblood vessel would not be sufficient to tolerate haemodialysis blood flows or cause


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    Fig. 1. Anteroposterior supine chest radiograph after

    placement of left internal jugular temporary venous

    haemodialysis catheter. The tip of the catheter

    projects upon the lateral aspect of the proximal

    descending aorta.

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    Fig. 2. Angiogram after injection of contrast through

    the tip of the haemodialysis catheter. The left

    brachiocephalic vein is occluded. The distal tip of the

    catheter (white arrowhead) is located within a large

    superior intercostal vein (long white arrow). The

    superior intercostal vein communicates with the

    accessory hemiazygos vein (thin black arrow) which

    drains into the azygos system (short white arrow).

    The thick black arrow is the SwanGanz catheter.

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    Hypoplasia or absence of the brachiocephalic vein necessitates alternate pathwayswhereby blood from the left upper extremityand left internal jugular vein may reach the

    right atrium. Possibilities

    include a persistent left sided superior vena cava which drains

    into the coronary sinus, as well as several variations through which blood drains viasuperior intercostal veins into the accessoryhemiazygos vein and subsequently into theazygos system [2].

    The left paramedian location of the catheter on the anteroposteriorradiograph raised thepossibility of placement in a remnant left-sided superior vena cava, or internal thoracic(mammary) vein which runs anteriorly [36], or superior intercostal vein which runsposteriorly [710] (Figure 3 ). Placement in the pericardiophrenic vein was possiblealthough less likelyas it usually runs laterally along the cardiac border [1114].A lateralfilm would have been helpful in distinguishing thesepossibilities but was difficult given

    the requirement for ventilatory