PIN PB PAPDI XVII Surabaya, 2019

PEMASANGAN KATETER VENA SE

Arif Mansjoer
Cardiac ICU Pelayanan Jantung Terpadu RSCM
Divisi Kardiologi Departemen Ilmu Penyakit Dalam FKUI/RSCM
Curriculum Vittae
• Nama : Arif Mansjoer
• Pendidikan :
• 1999 Dokter Umum FKUI
• 2005 Spesialis Penyakit Dalam FKUI
• 2008 Konsultan Intensive Care FKUI
• 2014 Magister Epidemiologi, FKM UI
• 2017 Konsultan Kardiovaskular, FKUI
• Pekerjaan :
• Cardiac Intensive Care Unit Pelayanan Jantung Terpadu RSCM
• Divisi Kardiologi Departemen Ilmu Penyakit Dalam FKUI/RSCM
• Intensive Care Unit, RS Jantung Jakarta
Kompetensi
a. Daftar Pokok B ahasan Penyakit dan Keterampilan Utama
Tabel I. Daftar Pokok Bahaearı Penyamt darı Ketrraınpilan tJesum

Peru ba han kesadaran

b. Sinkope
fi tatu s epilep tiku s
d. Nyeridada akut
H enM,syok
A ritmia mcngancam kehidupan
Hiperfensi berat

Resusitasi janmng pam

k. Basic Life Support

m. Penısxangan katcter vena aentr&

b, Daftar Pokök Bahasan Keterampilan Tai hattan

USG tiroii:t
2 Moptalmometry in tirou ’s d seose
3 tirainasc ag irasi abeee hati
fYonsíent ernst ra h ‘broscan
5 As irasi kista hati
6 Membara apusari sumsum tulang terkait : kcBenasan
hemato!o ’k lain
7 Pemberian a en anti kanker e iotera i a es‘
Pembuaian dan embacaan sediaan a usan darah te i
flkokardio afi. TY nsihorncik echocord' nzm
Melakukan inte rctasi hasil mill Test
11 Do ler vaskular mbuluh darah te dan carotis
iz Pcmasan katctcr vena central
J 3 Bronkoeko i fleksibel
J4 nine behauiour the
t s Tera i aliatif
16 Artroeentesie dan injeksi
lrıtraartikular pada bczbagai scndi besar : Bahu, Talokrural,
Subtalar
J 7 Artroaenteais dan injeksi sendi kecil (PIP, DIP, ariel, MCP,
MMC, tarxometatareal
18 IJSG mvıokuloekeletal
5, Bidang Oin)al Hipertensi

Pcritonee2 dialisia mandiri berkesimambungau

(katetcr Tenchkoff)
Tranaplentxai gimjal lmanajemcn di bidang penyakit $
da1am pra dax pasca)
Ultranono$mfi ginjal den saluran Rmih
l•emaeangan katcter foßcy 4A
6 Pca\asstngex doubfe Mrnen katetcr 2.
Biopsi ginjaJ
8. 2
9 Perttoneq1 diaJiaia elcut 2
IO
 6. Bidarig Hcmatologi Onkologi Medik

1 16 Flebotorrń
17
I IB Menga@ai p srdaxa han medik/gaztgguan hcmos
19 &maaaogan nutriket / ks¢etcr vena sertttzït
Pemberian Obat darz Tcrapi SiBtCzDïk pada IBAN
- Pembe1-isn agen anÖ kan&r (kcmoterapi 4A
- Pemberian agen stand«tr|
anti kanRr (kemoterapi egrneiQ
- Terapi target ael kanker
- Terapi hnrmnrial
Terapi biolngik (grnuzth /octor, aitokin) 4A
Rrapi xuportif padh kanknr (febrilc
neutrnpcxiia, nyeri, Ö sto8fnnat, muai/muntah, 4A

Teapi antikoagulan, anó agregasź tzamóosit,

trumbońŃk dsn pemaritauannya
7. Bidang Kardiovaskular

Doppler vaakular pembuluh darah tepi dan carotte îï

Perikardiosinfee is 2
1i Peniaaazigan kateur vent central
12 Rmæaamgart akscs vena perifer 4A
J3 PeIDax&mgam etidOtrB€ÛeoÎ Abe 4A
i4 Etecimph9siolo9iy uiuä9 ü
i5 mtctcriaasi Jantung 3
16 fingiogrgPi Knroner 2
17 Paca jaritxirig. sementnra J fræwsient pesœ nioker 2
18 Par jantur g prrmaricri / permnaeri1 maker 2
19 Kateter ablasi 2
20 Tes nnkk brochinf iiidex 4A
8. Bidang Pulmonotogi

to Bror›kos\copi flcksibe1 2
11 I¥ons bronchial rfeed/e ac#irarién(T8XA) 2
12 2Tuns bronchió t lutig biopsp{T8LBJ 2
13 Endo bmnnNaI ultro sonoqrophq z T8NA 2
14 8ronkoakopi rigid à
15 Stcnt bronchial 2
I» Cio our;yer¿f duri fnser theropy 1
lT brorichiof thermo@estp 1
ia Ventilati nnninvasif 3
i9 Intuhaei endotrakeal 4A
?0 Ventilasi mtkanik 3
Percutaneous dilatational tracheostomy dan $
P ras atam trakeostomi
zz U5G Toraks
23 sleep studies 2
24
2S Terapi inhalaai 4A
Pemasangan Kateter Vena Sentral
• Anatomi vena
• Indikasi
• Manfaat
• Kontraindikasi
• Komplikasi pemasangan
• Komplikasi penggunaan jangka Panjang
• Cara mencegah infeksi nosokomial
Anatomi
• Vena Jugularis Interna

• Vena Subklavia

• Vena Femoralis
Anatomi: v. jugularis interna
Anatomi: v. jugularis interna
V. jugularis interna: Anatomical landmark
V. jugularis interna: Anatomical landmark
V. Jugularis interna: Central approach
V. Jugularis interna: Anterior approach
V. Jugularis interna: Posterior approach
Anatomi: v. subklavia
V. subklavia: Infraclavicular approach
V. subklavia: Infraclavicular approach
Scalenus anterior Sternocleidomastoid
muscle muscle
Subclavian
artery Clavicle

Dome of
pleura Subclavian
vein

Pectoral
muscles

First rib
V. subklavia: supraclavicular approach
Anatomi: v. femoralis
Anatomi: v. femoralis
 Tanpa Kompresi Dengan Kompresi

Tanpa Kompresi Dengan Kompresi Netral Eksorotasi

Pemilihan Akses Sentral
• Risiko infeksi
• Risiko trombosis
• Risiko stenosis
• Risiko pneumotoraks
• Kemudahan ‘tunneling’ dan akses ‘port’
• Kemudahan insersi
• Kestabilan
• Pengalaman dan kemampuan operator
• Ketersediaan dan kemampuan menilai USG dan
foto toraks
Pemilihan Akses Vena Sentral
Akses Vena Keuntungan
V subklavia Risiko infeksi rendah
Sesuai untuk
subcutaneous tunneling
dan port access
V jugularis Vena dapat dilihat secara klinis
interna maupun dengan USG
Aksesnya mudah pada pasien yang
sedang menjalani pembedahan
Pada sisi kanan, ujung kateter
hampir selalu pada tempatnya
V femoralis Risiko perdarahan rendah
Pasien dapat tetap duduk saat
pemasangan
Kerugian
Risiko perdarahan tinggi
Risiko pneumotoraks tinggi
Prosedur ‘blind’ yang sukar
dipandu dengan USG
Risiko infeksi sedang
Risiko perdarahan sedang
Sukar untuk membuat tunnel
Sukar untuk ditutup
Tidak nyaman bila tidak di-
tunnel
Risiko infeksi tinggi
Risiko trombosis tinggi
Fungsi akan terganggu bila
pasien berdiri
Indikasi Pemasangan
Akses Vena Sentral
Kesulitan akses perifer
Pemberian cairan, elektrolit, vasoaktif

Nutrisi parenteral

Elektrolit pekat

Inotropik/ vasoaktif
Penilaian tekanan darah
Pengambilan sampel darah rutin,
ScVO2, dan SvO2 (mixed vein)
Akses terapi pengganti ginjal

Non-tunneled

• Hemodialisis
• SLEDD
• CRRT

Tunneled
Akses pacu jantung

permanent
temporary
 Kontraindikasi
1. Pasien gaduh gelisah, delirium, atau
tidak kooperatif
2. Area insersi mengalami infeksi atau luka bakar
3. Kelainan anatomi: kurus, gemuk, riwayat radiasi
4. Gangguan hemostasis: trombosis,
DIC, penggunaan terapi antikoagulan
5. Pascaprosedur: mastektomi, tiroidektomi, AV
shunt
 Indikasi Pemasangan Akses
1. Pemasangan akses vena perifer yang sukar
2. Pemberian cairan osmolaritas tinggi atau pekat dan
obat khusus:
• Cairan dengan, seperti nutrisi parenteral, elektrolit pekat
• Obat kemoterapi
• inotropik, vasopresor, vasodilator
3. Pengukuran CVP, RAP, RVP, PAP, PCWP
4. Pengambilan darah untuk menilai ScvO2 atau SvO2
5. Pemasangan akses terapi pengganti ginjal baik
hemodialisis intermiten atau CRRT
6. Pemasangan akses pacu jantung dan
intervensi jantung
 Komplikasi
Komplikasi V.jugularis interna V.subklavia V.femoralis
Pungsi arteri 3% 0,5 % 6,25 %
Hematoma < 0,1 – 2,2 % 1,2 – 2,1 % 3,8 – 4,4 %
Hemototoraks Tidak ada 0,4 – 0,6 % Tidak ada
Pneumotoraks < 0,1 – 0,2 % 1,5 – 3,1 % Tidak ada
Malposisi Risiko ringan (masuk ke Risiko tinggi Risiko rendah
vena kava inferior (melewati v subklavia (mengenai pleksus
melalui atrium kanan) kontralateral, naik v vena lumbal)
jugularis interna)
Trombosis 1,2 – 3/1000 hari 0 - 13 /1000 hari 8 - 34 /1000 hari
kateter kateter kateter
Infeksi 8,6 /1000 hari 4 /1000 hari 15,3 /1000 hari
kateter kateter kateter
Komplikasi
Saat pemasangan Setelah pemasangan
1. Nyeri 1. Infeksi
2. Perdarahan 2. Trombosis
3. Pneumotoraks
4. Emboli udara
5. Aritmia
Pencegahan Infeksi Nosokomial
 Concatz0na¢nd
Endogenous
Extrinsic
Auld
Skin erganlcms Endoger›o
Extrinsic Intrinsic
UC'/ hands

Nematogenous
from dlsram infection

Figure 2-1. Routes for Central Venous Catheter Contamination witb

Microorganisms
Potential sources of i«Iécdon of e percutaneous iraave9cuWae*Jcs (ivoy the cont skin n‹xe. contamination af
Who catheter hub and lumen, nt 'ninaliori of infñsate, and stonaabort of the
IVO fr‹xn distant unrelated sites of infection. MCI fzx¥th care woñ‹ez.
Selection of Catheters and Sites
1. Weigh the risks and benefits of placing a central
venous device at a recommended site to
reduce infectious complications against the risk
for mechanical complications Category IA
2. Avoid using the femoral vein for central venous
access in adult patients. Category 1A
3. Use a subclavian site, rather than a jugular or a
femoral site, in adult patients to minimize
infection risk for nontunneled CVC placement.
Category IB
Selection of Catheters and Sites
4. No recommendation can be made for a preferred site
of insertion to minimize infection risk for a tunneled
CVC. Unresolved issue
5. Avoid the subclavian site in hemodialysis patients
and patients with advanced kidney disease, to
avoid subclavian vein stenosis. Category IA
6. Use a fistula or graft in patients with chronic renal
failure instead of a CVC for permanent access
for dialysis. Category 1A
7. Use ultrasound guidance to place central venous
catheters (if this technology is available) to reduce
the number of cannulation attempts andmechanical
complications. Ultrasound guidance should only be
used by those fully trained in its technique.
Category 1B
Selection of Catheters and Sites
8. Use a CVC with the minimum number of ports or
lumens essential for the management of the
patient. Category IB
9. No recommendation can be made regarding the use
of a designated lumen for parenteral nutrition.
Unresolved issue
10. Promptly remove any intravascular catheter that is no
longer essential. Category IA
11. When adherence to aseptic technique cannot be
ensured (i.e catheters inserted during a medical
emergency), replace the catheter as soon as
possible, i.e, within 48 hours. Category IB
 §entraI Line Insertion Checklist — Template
Patient Name/ID#: Unit: Room/Bed:
Date: Start time: End time:
Procedure Location: (Operating Room / Radiolagy / Intensive Care Unit / Other:
Person Inserting Line: Person Completing Form:
Catheter Type: (Dialysis / Tunneled / Non-tunneled / Implanted / Non-implanted / Peripnerally Inserted Central Gatheter)
Impregnated: {Yes/No) Number of Lumens: (1, 2, 3, 4) Catheter Lot Number:
Insertion Site: (Jugular / cnest / Subclavian / Femoral / Scalp / Umbilical) Side of Body: (Lelt / Right)
Reason for Insertion: (New indication / Malfunction / Routine Replacement / Emergent) Guide Wire Used: (Yes/Na)

Critical Steps Yes No“ ma Comments

Reminder
BEFORE the procedure:
Patient is educated about the need for and implications af the
central line as well as the praœsses of insertion and
maintenance
Patient’s latex/adhesive allergy assessed (modfy suppliesJ
Patient’s infection risK assessed. If at greater risK, why?
Patient’s anticoagulation therapv status assessed
Consent form and ather relevant documents complete and in
chart (Exoeption. Ernergerit Prooe‹Jrire}
Operatar and Assistant used appropriate hand hygiene
immediateh’
Equipment assembled and verilied—materials, medications,
svringes, dressings, and labels
Placement confirmation metnȟ readied
Patient identilied witn 2 sources of identification
Procedural time-out perlormed
Site assessed and marKed
Patient positioned Tar procedure
SKin prep performed with alc»n»lic chlorhexidine greater than
0.5°4 (unless under 2 months of age) ar tincture oT iadine ar an
iodophar or alcohol
SKin prep allawed to dry priar to puncture
Patient’s body covered by sterile drape from nead to tae
AII those performing procedure using sterile gloves, sterile
qawn, haVcap, mask, and eye protection/shield
Others in room wearing mask
Catheter preflushed and all lumens clamped
Local anesthetic and for sedation used
DURING the procedure. If‘Mo’ for any ‘DLIfdNG the procedure' criôcal îtezrœ end the proœdure.
Confirmation of venous placement PRIOR TO dilatation of vein
by. ultrasound/ transesophageal echmardiogram / pressure
transducer / manomètre method / fluoroscopy
Blood aspirated from each lumen (intravascular placement
assessedJ
Type and Dœage {mL/ùnits) af Ilush
Catheter caps placed on lumens
Æl lumens clamped (should not be done with neutral or positive
displacement conneoorsJ
Catheter secured (sutured /stapIed /steri-s01ppedJ
Tip position confirmation via nuaroscopy oR enest X-ray
Stedle lield mainBined
Lumens were not cut
Qualified seœnd aperator obtained after 3 unsuccessful sticks
Blood cleaned from site
Sterile dressing applied (gauze, transparent dressing, gauze
and transparent dressinq, antimicrabial foam dise)
AFTER Vie procedure.
Dressing dated
Verify plaœment by x-ray
“Approved for use" sitting on dressinq after œnfirmation
If a femaral line placed, elective PIC plaœment ordered
Central line fmaintenance) order placed
Patient is educated about maintenance as needed
“ Procedure Deviation: If there is a deviation fzom process, immediately notîfy the operator and stop the procedure untel corrected.
Procedure Notes/Comments:
Catheter Measurements: External length Internal length
Distribution lnstmctions: Please return the completed form to the designated person in your area.

The Joint Comrmssion. May be adapted for internal use. Suggested citagon: The Joint Commission. &reven//ng Ce 0a/ Lin ssociated
Bkxxlstream Infections.- Llseful Tools, An /nfema/lava/ Pms/›ec/ive. Nov 20, 2013. Accessed [user please fill in access date].
Terima kasih
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