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
SMART_READER_LITE
LIVE PREVIEW

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

May 17, 2023 7 likes •509 views

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

slide-1
SLIDE 1

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

slide-2
SLIDE 2

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

slide-3
SLIDE 3

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
slide-4
SLIDE 4

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
  • bram yc in (3)
  • Ve no us I

rrita nts

  • Am pho te ric in B
slide-5
SLIDE 5

WHICH BE COME S AN E ME RGE NCY? ?

Vaso pre sso rs

slide-6
SLIDE 6

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

slide-7
SLIDE 7

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
  • c a lize d Ce llulitis
  • Ble e d ing
  • E

xc e ssive Blo o d L

  • 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)
slide-8
SLIDE 8

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)

slide-9
SLIDE 9

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

slide-10
SLIDE 10

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
  • c a lize d Ce llulitis
  • Ble e d ing
  • E

xc e ssive Blo o d L

  • 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)
slide-11
SLIDE 11

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

slide-12
SLIDE 12

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)
slide-13
SLIDE 13

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

slide-14
SLIDE 14

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

  • JUSTas 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

slide-15
SLIDE 15

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
slide-16
SLIDE 16

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

slide-17
SLIDE 17

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
slide-18
SLIDE 18

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

  • w Card iac Output (WIT

H Maintaine d BP)

  • Ad ve rse E

ffe c ts:

  • Hypo te nsio n
  • T

ac hyarrhythmias

slide-19
SLIDE 19

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

  • 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

  • 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

slide-20
SLIDE 20

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

slide-21
SLIDE 21

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
slide-22
SLIDE 22

PHE NT OL AMINE ADMINIST RAT ION

  • Ad ministe re d ASAP
  • E

ve n if Are a L

  • 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
slide-23
SLIDE 23

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

slide-24
SLIDE 24

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)

slide-25
SLIDE 25

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

slide-26
SLIDE 26

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
  • 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

slide-27
SLIDE 27

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
slide-28
SLIDE 28

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
  • ng Ha s She Ha d Na use a a nd Vo miting ?
slide-29
SLIDE 29

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
  • 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?

slide-30
SLIDE 30

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
  • 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?
slide-31
SLIDE 31

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

slide-32
SLIDE 32

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

  • PI

CC L ine Pla c e me nt Pla nne d fo r the AM

  • Ha s One 22G Pe riphe ra l a fte r L
  • sing Othe r 18 G PI

V a b o ut 30 minute s a g o

slide-33
SLIDE 33

CASE # 2 DISCUSSI ON

  • Do e s T

his Pa tient Ne e d a Ce ntra l L ine ?

  • Wha t is the Appro pria te MAP fo r a Pa tie nt with E

SL D?

  • I

f Yo u De te rmine T he y Do n’ t Ne e d a T L C, Why Pla c e a PI CC?

  • Wha t Are Yo ur L

imiting Fa c to rs?

  • Ag e
  • Me nta tio n
  • Che c k/ T

rea t Ammo nia L e vel

slide-34
SLIDE 34

CASE # 2 DISCUSSI ON

  • Do e s T

his Pa tient Ne e d a Ce ntra l L ine ?

  • Wha t is the Appro pria te MAP fo r a Pa tie nt with E

SL D?

  • I

f Yo u De te rmine T he y Do n’ t Ne e d a T L C, Why Pla c e a PI CC?

  • Wha t Are Yo ur L

imiting Fa c to rs?

  • Ag e
  • Me nta tio n
  • Che c k/ T

rea t Ammo nia L e vel

  • Wha t Othe r Optio ns Do Yo u Ha ve ?
  • Optimize Mido drine
  • Bridg e to Po te ntia l L

ive r T ra nspla nt

slide-35
SLIDE 35

CASE PRE SE NT AT ION # 3

  • An 87 yo Fe ma le with E

nd-Sta g e Co ng e stive He a rt Fa ilure , Hypo te nsio n, Hypo xia a nd + 3 Ana sa rc a

  • Curre nt BP 68/ 36, HR 94, SpO2 91% o n 6 L

NC

  • Pre se nt Ac c e ss – 22 G PI

V

  • Co de Sta tus: F

ull

slide-36
SLIDE 36

CASE PRE SE NT AT ION # 3

  • An 87 yo Fe ma le with E

nd-Sta g e Co ng e stive He a rt Fa ilure , Hypo te nsio n, Hypo xia a nd + 3 Ana sa rc a

  • Curre nt BP 68/ 36, HR 94, SpO2 91% o n 6 L

NC

  • Pre se nt Ac c e ss – 22 G PI

V

  • Co de Sta tus: F

ull

  • Alb umin Bo lus F

a ils to I nc re a se BP

  • Pa tie nt is Re fusing ABG, Ce ntra l L

ine Pla c e me nt

  • Wa xing a nd Wa ning Me nta l Sta tus
slide-37
SLIDE 37

CASE # 3 DISCUSSI ON

  • Do e s T

his Patie nt Ne e d a Ce ntral L ine ?

  • Ho w Do e s T

his Cha ng e if PI V is L

  • st?
  • Wha t if a PI

CC Co uld b e Pla c e d in 4 Ho urs?

  • Wha t if Pa tie nt is Cha ng e d to a DNR?
  • Wha t if Yo u Ca n’ t Ge t Aho ld o f the F

a mily?

  • What Are Yo ur L

imiting Fac to rs?

  • Se ve rity o f I

llne ss

  • Ag e
  • Pa tie nt Co mfo rt – Co mmunic ate
slide-38
SLIDE 38

CASE PRE SE NT AT ION # 4

  • 93 yo Ma le with Hypo na tre mia (Na 114)
  • VSS
  • Ab no rma l Me nta tio n
  • Curre nt Ac c e ss: T

wo 20 G PI Vs

  • Histo ry o f Se izure s
  • Unkno wn if Ac ute o r Chro nic
  • No Histo ry o f E

T OH

slide-39
SLIDE 39

CASE # 4 DISCUSSI ON

  • Do e s T

his Pa tient Ne e d a Ce ntra l L ine ?

  • Wha t if Pa tie nt is DNR?
  • Wha t if BP is 103/ 34 – MAP 57
slide-40
SLIDE 40

CASE # 4 DISCUSSI ON

  • Do e s T

his Pa tient Ne e d a Ce ntra l L ine ?

  • Wha t if Pa tie nt is DNR?
  • Wha t if BP is 103/ 34 – MAP 57
  • Wha t Are Yo ur T

re a tme nt Optio ns?

  • 2% Sa line T

hro ug h a PI V

  • T

re a t to SBP > 90; NOT MAP

slide-41
SLIDE 41

UNIQUE ME DICAL CONSIDE RAT IONS

# 1 – Do n’ t F a il to Utilize a Me dipo rt, I O, PI CC o r Midline if Availab le # 2 – E SL D MAPs MAY Be Appro pria te a t 50-55

Me ntatio n is Ke y

# 3 – Do n’ t F a il to Re c o g nize So me o ne a t E nd o f L ife

Co mmunic ate E

ffe c tive ly with the Pa tie nt a nd F a mily # 4 – Hypo na tre mia Ca n Be T re a te d with 2% Saline T hro ug h a PI V I f 3% Sa line is Re q uire d – Ce ntra l Ac c e ss is Re q uire d # 5 – MAPs in E lde rly Ma y Be Misle ading T itra te Pre sso rs/ De te rmine T re a tme nt Ba se d o n SBP > 90 + Me ntatio n

slide-42
SLIDE 42

SUMMARY POINT S

  • De sp ite Co mmo n Be lie f, Ce ntra l L

ine Pla c e me nt is NOTAlwa ys Ne c e ssa ry

  • Pre sso rs CAN Be Give n T

hro ug h a Pe rip he ra l L ine

  • Ma ximum Do se s
  • Va rio us Drug s
  • Nume ro us Op tio ns Exist F
  • r Va sc ula r Ac c e ss
  • L

OOKa t Yo ur Pa tie nt – No t Just T

he ir Numb e rs

  • Kno w the Alte rnative s
slide-43
SLIDE 43

F UT URE ARE AS OF RE SE ARCH

  • E

a sie r/ Sa fe r Ve no us Ac c e ss Optio ns

  • Ma ximum Pe riphe ra l Me dic a tio n Do se s
  • Alte rna tive Pre sso r Me c ha nisms o f Ac tio n
  • Additio na l E

xtra va sa tio n T re a tme nt Optio ns

slide-44
SLIDE 44

RE F E RE NCE S

  • http:/ / hwc dn.lib syn.c o m/ p/ a / 2/ 9/ a 2983a 05a 2f30507/ E

MCrit-Po dc a st-20130916-107- pe riphe ra l-va so pre sso rs- e xtra va sa tio n.mp3? c _id=6147150&e xpira tio n=1443861432&hwt=3fb a e 738922257c 7a 503a db ff50e dc 20

  • http:/ / www.drug s.c o m/ pro / ne o -syne phrine -inje c tio n.html
  • BE

RBE N, J Y, M F BRYANT , a nd J M HOWARD. 1957. E tio lo g y a nd pre ve ntio n o f slo ug hs pro duc e d b y L

  • no re pine phrine (le vo phe d). Annals o f surg e ry, no . 6.

http:/ / www.nc b i.nlm.nih.g o v/ pub me d/ 13488384.

  • Bunke r, Nic k, a nd Da vid Hig g ins. 2006. Pe riphe ra l a dministra tio n o f va so pre ssin fo r

c a te c ho la mine -re sista nt hypo te nsio n c o mplic a te d b y skin ne c ro sis. Critic al c are me dic ine , no . 3. http:/ / www.nc b i.nlm.nih.g o v/pub me d/ 16505698.

  • Che n, J L

, a nd M O’ She a . 1998. E xtra va sa tio n injury a sso c ia te d with lo w-do se do pa mine . T he Annals o f pharmac o the rapy, no . 5. http:/ / www.nc b i.nlm.nih.g o v/ pub me d/ 9606475.

slide-45
SLIDE 45

RE F E RE NCE S

  • Ric a rd, Je a n-Da mie n, L

a ure nc e Sa lo mo n, Ale xa ndre Bo ye r, Guilla ume T hie ry, Ag ne s Me yb e c k, Ca rine Ro y, Bla ndine Pa sq ue t, E ric L e Miè re , a nd Didie r Dre yfuss. 2013. Ce ntra l o r pe riphe ra l c a the te rs fo r initia l ve no us a c c e ss o f I CU pa tie nts: a ra ndo mize d c o ntro lle d tria l. Critic al c are me dic ine , no . 9. do i:10.1097/ CCM.0b 013e 31828a 42c 5. http:/ / www.nc b i.nlm.nih.g o v/ pub me d/ 23782969.

  • ZUCKE

R, G. 1957. Use o f phe nto la mine to pre ve nt ne c ro sis due to le va rte re no l. Jo urnal o f the Ame ric an Me dic al Asso c iatio n, no . 16 ( 20). http:/ / www.nc b i.nlm.nih.g o v/ pub me d/ 13415911.

  • ZUCKE

R, G, R P E I SI NGE R, M H F L OCH, a nd M M SI NGE

  • R. 1960. T

re a tme nt o f sho c k a nd pre ve ntio n o f isc he mic ne c ro sis with le va rte re no l-phe nto la mine mixture s. Circ ulatio n. http:/ / www.nc b i.nlm.nih.g o v/ pub me d/ 13788877.

  • Ka ma l Me dle j., e t a l. “ Co mplic a tio ns fro m the Administra tio n o f Va so pre sso rs

thro ug h Pe riphe ra l Ve no us Ca the te rs: An Ob se rva tio na l Study”. E C Ana e sthe sia 2.1 (2015): 61-68.

slide-46
SLIDE 46

RE F E RE NCE S

  • http:/ / www.e me dic ine he a lth.c o m/ ve no us_ac c e ss_devic e s/ pa g e3_e m.htm
  • http:/ / www.nc b i.nlm.nih.g ov/ pmc / artic le s/ PMC2682308/
  • http:/ / www.upto date .c o m/ c o nte nts/ use -o f-vaso pre sso rs-a nd-inotro pe s
  • http:/ / www.ivs1.c o m/ima ge s/ c e ntra lline .pdf
  • http:/ / www.upto date .c o m/ c o nte nts/ use -o f-vaso pre sso rs-a nd-inotro pe s
  • https:/ / www.nic hd.nih.g ov/ c o c hra ne _da ta / go pa la kr

ishna np_01/ go pa la kr ish na np_01.html

slide-47
SLIDE 47

RE F E RE NCE S

  • K

ahn, Je re m y M, Jo hn P K re ss, and Je sse B Hall. 2002. Skin ne c ro sis afte r e xtravasatio n o f lo w-do se vaso pre ssin adm iniste re d fo r se ptic sho c k. C ritic al c are m e dic ine , no . 8. http:/ / www.nc bi.nlm.nih.g o v/ pubme d/ 12163813.

  • K

han, Manso o rS, and J D Ho lm e s. 2002. Re duc ing the m o rbidity fro m e xtravasatio n injurie s. Annals o f plastic surg e ry, no . 6. http:/ / www.nc bi.nlm.nih.g o v/ pubme d/ 12055433.

  • MC GINN, J T

, and J SC HL UGE

  • R. 1956. Skin slo ug hs asso c iate d with le vo phe d;

patho g e ne sis, pre ve ntio n and tre atm e nt. Am e ric an jo urnal o f surg e ry, no . 4. http:/ / www.nc bi.nlm.nih.g o v/ pubme d/ 13362728.

  • PE

L NE R, L , S WAL DMAN, and M G RHOADE

  • S. 1958. T

he pro ble m o f le varte re no l (le vo phe d) e xtravasatio n an e xpe rime ntal study. T he Am e ric an jo urnal o f the m e dic al sc ie nc e s, no . 6. http:/ / www.nc bi.nlm.nih.g o v/ pubme d/ 13606129.

  • Raszka, W V, T

K K ue se r, F R Sm ith, and J W Bass. 1990. T he use o f hyaluro nidase in the tre atm e nt o f intrave no us e xtravasatio n injurie s. Jo urnal o f pe rinato lo g y : o ffic ial jo urnal o f the C alifo rni a Pe rinatal Asso c iatio n, no . 2. http:/ / www.nc bi.nlm.nih.g o v/ pubme d/ 2358898.

slide-48
SLIDE 48

IMAGE CRE DIT S

  • http:/ / e m e di

c i ne .m e dsc ape .c o m / arti c le / 908610-o ve rvi e w

  • https:/ / m o ri

ng am e di c i nals.c o m / c o ntra

  • http:/ / e m c ri

t.o rg / po dc asts/ pe riphe ral-vaso pre sso rs-e xtravasa ti

  • n/
  • http:/ / www.we bm e dc e ntral.c o m / arti

c le _vi e w/ 2261

  • http:/ / www.m e de te c .c o .uk/ sli

de %20sc ans/ m i sc e llane o us/ targ e t8.htm l

  • http:/ / www.bri

g ham andwo m e nsfaulkne r.o rg / a bo ut-us/ g e ne ral-i nfo rm ati

  • n/ bwfh-ne ws/ I

m pro vi ng - fe e dbac k-abo ut-pati e nt-safe ty.aspx

  • https:/ / www.li

nke di n.c o m / pulse / c e rti fi e d-pro fe ssi

  • nal-pati

e nt-safe ty-e xam -study-silvi a-c alzad a-g i l

  • http:/ / pai

ni njuryre li e f.c o m / pm i r-take s-pa ti e nt-safe ty-to -the -hi g he st-le ve l/

slide-49
SLIDE 49

IMAGE CRE DIT S

  • http:/ / pai

ni njuryre li e f.c o m / pm i r-take s-pa ti e nt-safe ty-to -the -hi g he st-le ve l/

  • http:/ / www.bri

g htstarc are .c o m / sw-pi ttsburg h/ 2012/ 03/ 17/ what-we -all-m ust-do -to -i m pro ve -safe ty- i n-o ur-ho m e s/

  • http:/ / li

vi ng wi thg p .c o m / e xpe ri e nc e s/ tpn/

  • http:/ / www.g anfyd.o rg / i

nde x.php ? ti tle =Fi le :Ce ntral_li ne _who le .JPG

  • www.i

c ufaqs.o rg

  • www.we bsi

te m ag azi ne .c o m 5000

  • www.7-the m e s.c o m
  • http:/ / www.g e rm ano s-m e di

c als.g r/ p ro duc ts/ kathe ti ras-tho rako s-m e -tro kar

slide-50
SLIDE 50

T ha nk Yo u! QUE ST I ONS?