Sheath introducer
Contents
Overview
- Long (6-8cm), wide bore (6-9 Fr) single lumen catheter typically placed in a central vein
- Have wide plastic hub on proximal end with one-way valve
- Can be used to insert triple lumen catheter, Swan-Ganz catheter, and temporary external pacing wires
- Commonly used for rapid fluid or blood administration (especially in trauma resuscitation)
- Can infuse close to 600 ml/min with pressure[1]
- Cordis and MAC are both trade names commonly used for sheath introducers
Indications
- High volume/flow resuscitation (e.g. hemorrhagic shock)
- Emergency venous access
- Inability to obtain peripheral venous access
- Repetitive blood sampling
- Administering hyperalimentation, vasopressors, caustic agents, or other concentrated fluids
- Insertion of pulmonary artery catheters
- Insertion of transvenous cardiac pacemakers
Contraindications
Absolute[2]
- Infection over the placement site
- Anatomic obstruction (thrombosis of target vein, other anatomic variance)
- Site-specific
- Subclavian - trauma/fracture to ipsilateral clavicle or proximal ribs
Relative
- Coagulopathy (see below)
- Of higher concern compared to triple-lumen catheters given large-bore nature of sheath introducer
- Distortion of landmarks by trauma or congenital anomalies
- Prior vessel injury or procedures
- Morbid obesity
- Uncooperative/combative patient
Central line if coagulopathic
- Preferentially use a compressible site such as the femoral location (avoid the IJ and subclavian if possible)
- No benefit to giving FFP unless artery is punctured[3]
- However, consider giving FFP if patient has hemophilia[4]
Equipment Needed
- Kit typically contains:
- Chlorhexidine
- Sterile drape
- 1% lidocaine without epinephrine
- 5 mL syringe (for lidocaine)
- 22-ga and 25-ga needles (for lidocaine)
- 5-10 mL syringe (for venipuncture)
- 18-ga needle (for venipuncture)
- Guidewire
- Scalpel with 11-blade
- Dilator
- Introducer sheath
- Catheter clamp
- Silk suture
- Sterile gown, cap, mask, gloves
- Biopatch
- Tegaderm
- Sterile saline flush
- Sterile caps for lumen ports
Procedure
Same procedure as central line placement according to site (see below) however the dilator must be pre-loaded into the line and the dilator-sheath is introduced over the wire simultaneously. Afterwards, the dilator and wire are removed together.
Complications
Complications vary by site
- Pneumothorax (more common with subclavian)
- Arterial puncture (more common with femoral)
- Catheter malposition
- Subcutaneous hematoma
- Hemothorax
- Catheter related infection (historically more with femoral)
- Catheter induced thrombosis
- Arrhythmia (usually from guidewire insertion)
- Venous air embolism (avoid with Trendelenburg position)
- Theoretically higher risk with sheath introducer compared to other CVC's
- Bleeding
See Also
Vascular access types
- Central venous catheterization
- Rapid infusion catheter
- Intraosseous access
- Venous cutdown
- Umbilical vein catheterization
- Ultrasound assisted peripheral line placement
- External jugular vein cannulation
- The "Easy IJ"
- Midlines
External Links
References
- ↑ Brown, N., Kaylene M. Duttchen, and J. W. Caveno. "An evaluation of flow rates of normal saline through peripheral and central venous catheters." American Society of Anesthesiologists Annual Meeting, Orlando. Anesthesiology. 2008.
- ↑ Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
- ↑ Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
- ↑ Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556