Akses

Vaskular
Indikasi Akses vena sentral

Kesulitan akses perifer

Memerlukan monitoring hemodinamik
Menggunakan obat-obatan yang merupakan
vasoaktif / phlebosklerotik
Pengambilan sampel darah vena yang berulang
Memasukkan obatMJ,obatan
Gahtan V, Costanza kemoterapi,
editors. Essentials of vascular surgery for theTPN
general surgeon.
Springer New York; 2015.
Kontraindikasi akses vena sentral

Kontraindikasi Absolut
• Trombositopenia atau Koagulopati Berat
 
Kontraindikasi Relatif
• Infeksi pada lokasi pemasangan atau luka bakar
• Fistula arteriovena ipsilateral untuk hemodialisa
• Trombosis vena disekitar lokasi pemasangan
• Pasien tidak kooperatif
• Anatomi yang tidak baik karena trauma atau operasi, obesitas
Gahtan V, Costanza MJ, editors. Essentials of vascular surgery for the general surgeon.
Springer New York; 2015.
Anatomi pemasangan Akses vena central

• Pemasangan akses vena sentral seringkali dilakukan

melalui akses pembuluh vena di bawah ini:
• Vena Jugular Interna (VJI)
• Vena Subclavian (VSC)
• Vena Femoralis (VFM)

Gahtan V, Costanza MJ, editors. Essentials of vascular surgery for the general surgeon.
Springer New York; 2015.
Vena subclavian dan jugular
 Akses Vena Internal jugular

• 95-99% berhasil dilakukan dan sedikit komplikasi

• Internal jugular kanan banyak dipilih karena lokasi
yang superfisial
• Sedikit komplikasi stenosis dan thrombosis
dibanding subclavian
• Visualisasi dari pemeriksaan USG yang lebih
mudah
• Lajur pembuluh darah yang relatif lurus langsung
ke vena kava superior
• Pada pasien dengan gagal ginjal mencegah
terjadinya stenosis vena subclavian yang
kemudian hari dapat mengganggu akses
hemodialisa melalui AV shunt
Gahtan V, Costanza MJ, editors. Essentials of vascular surgery for the general
surgeon. Springer New York; 2015.
Akses vena subclavian

• Dari supraklavikula atau infralavikula

• Lebih baik secara kosmetik
• Tidak untuk pasien dengan Hemodialisa, kecuali bila ekstremitas
atasnya kontraktur
• Bila dibandingkan dengan VJI:
• > Pungsi arteri
• > Malposisi
• = Risiko pneumothorak, hematohorak dan thombosis
Akses
vena femoral
Dapat untuk volum yang besar, contoh : hemodialisa dan
plasmapharesis

Memiliki risiko infeksi dan thrombosis yang lebih tinggi

dibandinkan VJI dan VSC

Dilepas secepatnya menghindari komplikasi

Seringkali dilakukan pada situasi emergensi ketika

prosedur intubasi maupun kompresi jantung paru
membatasi akses ke VJI dan VSC
Tipe Kateter

Critical care nephrology, 3rd ed, 2019, elsevier , CHAPTER 167

Vascular Access for Acute Renal Replacement Therapy
Persiapan pasien

• Informed Consent
• Monitoring dengan EKG dan pulse oksimetri
• Letakkan pasien dengan posisi supine dengan posisi kepala lebih
rendah 10-15 derajat lebih rendah  vena dapat terisi
• Bahu dapat diganjal dengan handuk gulung atau botol cairan
diantara kedua bahu
• Menggunakan USG
PERSIAPAN ALAT
Persiapan Peralatan
• Desinfektan
• Handscoen, masker, penutup kepala, jas
steril
• Spuit 10 ml 2 buah, jarum ukuran 25 Gauge
• Lidocain 1%
• Kateter, dilator dan wire
• Heparin 1: 100
• Jarum Insersi 21-Gauge ( panjang 5 cm)
• Duk steril, Scalpel, blade no. 11, benang
nylon no. 3.0
• Kidney dish, comb, kassa
• Needel holder dan gunting benang.
Teknik vena internal juguler
 Teknik vena internal juguler

• Septik aseptik
• Drapping
• USG guiding dan anestesi lidokain
• Menusuk kulit dengan jarum 21 G
• Diganti dengan 0.018 in guide wire
• Dilator 3 F dan 5 F
• Dimasukkan kateter vena sentral nontunel
• flushing dengan heparin
• Rontgen thorax
Sicard GA. Rutherford's Vascular Surgery and Endovascular Therapy. Journal of vascular
surgery. 2018 Nov 1;68(5):1611-2.
Location puncture central approach

Emergency medicine procedure

 Anterior Approach

Emergency medicine procedure

 Posterior Approach

Emergency medicine procedure

• Introduce a large caliber needle,
attached to a 10 mL syringe with
0,5 to 1 mL of saline, into the
center of triangle formed by the
two lower heads of
sternomastoid and clavicle.
• Ultrasound can be used as an
adjunct for the placement of
central venous line,

Sicard GA. Rutherford's Vascular Surgery and Endovascular Therapy. Journal of vascular
surgery. 2018 Nov 1;68(5):1611-2.
 • Insert the guidewire while
monitoring ECG for rhythm
abnormality
• Remove the needle while
securing the guidewire and
advance the catheter over
the wire. Connect the
catheter to the
intravenous tubing

Sicard GA. Rutherford's Vascular Surgery and Endovascular Therapy. Journal of vascular
surgery. 2018 Nov 1;68(5):1611-2.
Insersi CVC

• Posisi ujung CVC ± 2 cm dari perbatasan vena

cava superior dan atrium kanan dianggap
optimal.
• Lokasi ujung distal kateter diharapkan setinggi
karina atau vertebra thorakal 4-5 dimana di
lokasi ini ujung kateter berada diluar atrium, 2-3
cm dari perbatasan cavoatrial.
• Dengan mengukur jarak dari tempat insersi ke
sternal notch ditambah jarak vertikal dari sternal
notch ke karina pada rontgen thoraks.
Teknik vena Subclavian
Teknik vena Subclavian
Teknik vena Subclavian

• Akses Infraklavikula
• Beri ganjal pada bahu
• Kepala menghadap kontralateral
• Posisi tredlenberg 10-15 derajat
• Insersi pada 1-2 cm inferior dan lateral dari 1/3 medial dan 2/3 lateral
klavikula jarum walking down dan bila gagal jarum harus cephalad
• Akses supraklavikula
• Landmark 1cm superior dan 1 cm lateral terhadap otot sternocleidomastoid
• Jarum posisi 5-15 derajat

Tse A, Schick MA. Central Line Placement. 2019.

 Akses Vena femoral

• Bila mengalami trauma pada

extremitas atas
• Tidak menggganggu CPR saat
pemasangan
• Untuk hemodialisa emergensi

Tse A, Schick MA. Central Line Placement. 2019.

Teknik Vena femoral

• Posisis supinasi
• Landmark: 1 sd 2 jari dibawah garis dari anterior superior illiac
spine terhadap pubik tubercle. 1 cm medial dari femoral artery.
• Jarum diarahkan 90 derajat bila sudah dapat vena diarahkan 45
derajat
Teknik Vena femoral
Komplikasi
Venous Cutdown
 Indikasi

• Kelainan anatomi akses vena perifer

• Tidak terdapat vena untuk di kanulasi (Contoh: Syok
Hipovolemia, korban kebakaran, vena yang sclerosis, trauma)
• Akses vena darurat untuk infus atau transfusi
• Ketidaktersediaan akses vena sentral atau akses perifer yang
tidak terlalu invasif
 Kontraindikasi

Absolut
• Ketersediaan alat untuk akses vaskular yang tidak terlalu invasif atau tidak terlalu
memakan waktu
• Terdapat infeksi, jaringan yang rusak, luka bakar, dll pada area yang akan dilakukan
insisi (cutdown)
• Cedera traumatis di proksimal dari area insisi (cutdown)

Relatif
• Kelainan koagulasi
 Alat dan Bahan
• Sterile gloves
• Antimicrobial solution and swabs
• Kassa steril
• Local anesthetic (1 % lidocaine 5 mL)
• 5mL syringe, 10mL syringe
• 25- or 27-gauge needle
• Scalpel and Blade No.15
• Vein dilator
• Peripheral intravenous catheter
• Curved hemostat
• 0-0 silk sutures or 4.0 nylon sutures
• Iris scissors
• Intravenous infusion tubing
• Adhesive tape
ANATOMI
 Pemilihan Vena
• Greater saphenous vein: pembuluh darah terpanjang di tubuh, dominan di
subkutan, dapat diekspos minimal dengan diseksi tumpul di anterior medial
malleolus

• Basilic vein: berlokasi 1-2 cm lateral dari medial epicondyle di aspek anterior
humerus, diameternya relaltif memudahkan bahkan pada pasien hipotensi

• Cephalic vein: berjalan anteromedial dari aspek radial pergelangan tangan

menuju fossa antecubital, diameter besar dan superfisial, mudah dilakukan
kanulasi di lipatan flexor distal di fossa antecubital
 Saphenofemoral Vein

• The greater saphenous vein, yang mengalir ke femoral vein di area

infrainguinal, lokasinya konsisten
• Selama situasi emergency, terutama pada bayi kecil, teknik cutdown akan
secara cepat mengekspos greater saphenous vein di lipat paha
• Vena ini dapat mengakomodasi CVC yang besar untuk infus cairan, produk
darah dan obat-obatan
• Insisi secara transverse dibuat dibawah ligament inguinal, medial dari pulsasi
femoral
• Diseksi diselesaikan dengan hemostat yang “fine” , saphenous vein biasanya
diidentifikasi didaerah subkutan
• Walaupun dikhawatirkan terjadinya infEKsi karena lokasi yang dekat
perineum, naumn lokasi ini akan mengeliminasi risiko kmplikasi di thoraks dan
ditoleransi dengan baik tanpa peningkatan morbiditas
TEKNIK OPERASI

• Oleskan larutan desinfeksi ke kulit di sekitar daerah insisi.

• Buat bidang steril dengan menempatkan drape di sekitar area insisi.
• Pasang torniket proksimal dari lokasi sayatan untuk memaksimalkan
visualisasi vena.
• Injeksi anestesi lokal superfisial di kulit
• Insisi kulit dengan skalpel tegak lurus dengan jalur vena meIalui seluruh
lapisan kutan hingga jaringan lemak subkutan tervisualisasi
TEKNIK OPERASI
• Gunakan hemostat bengkok atau jari, secara tumpul diseksi
jaringan subkutan untuk mengisolasi dan mobilisasi sekitar 2-3
cm vena
• Retraktor yang kecil dapat digunakan pada situasi ini untuk
memperbaiki visualisasi vena
• Lewatkan benang dibawah vena distal dari lokasi penusukan
vena menggunakan hemostat untuk menstabilkan vena lalu ikat
benang
• Lewatkan benang ke 2 dibawah vena proksimal dari lokasi
penusukan vena menggunakan hemostat
• Insisi ½ hingga 1/3 diameter vena menggunakan scalpel dengan
sudut 45° terhadap pembuluh darah
• Masukkan ujung kateter ke insisi vena
• Kateter dapat langsung dimasukkan ke insisi kulit atau melalui
pungsi kulit di sekitar insisi
Komplikasi

• Hematoma
• Infeksi
• Sepsis
• flebitis
• Embolisasi
• Wound dehiscence
 1

INTRAVENOUS
CANNULATION
CANNULATION
“The aim of intravenous management is safe, effective delivery of treatment without discomfort or tissue
damage and without compromising venous access, especially if long term therapy is proposed”

Indications:

 Fluid and electrolyte replacement

 Administration of medicines
 Administration of blood/blood products
 Administration of Total Parenteral Nutrition
 Haemodynamic monitoring
 Blood sampling
41
ADVANTAGES
 Immediate effect
 Control over the rate of administration
 Patient cannot tolerate drugs / fluids orally
 Some drugs cannot be absorbed by any other route
 Pain and irritation is avoided compared to some substances when given
SC/IM

42
 EQUIPMENT
 Dressing Tray - ANTT
 Non Sterile Gloves / Apron
 Cleaning Wipes
 Gauze swab
 IV cannula (separate slide)
 Tourniquet
 Dressing to secure cannula
 Alcohol wipes
 Saline flush and sterile syringe or fluid to be administered
 Sharps bin

43
 PREPARATION
 Consult with patient
 Give explanation
 Gain consent
 Position the patient appropriately and identify the non-dominant hand / arm
 Support arm on pillow or in other suitable manner.
 Check for any contra-indications e.g. infection, damaged tissue, AV fistula etc.

44
 CANNULATION

Encourage venous filling by:

 Correctly applying a tourniquet (A tourniquet should be applied to the patient’s
upper arm. The tourniquet should be applied at a pressure which is high enough to
impede venous distension but not to restrict arterial flow)
 Opening and closing the fist
 Lowering the limb below the heart

45
SITE CHOICE
 Identify a suitable vein
 What are the signs of a good vein ?
 Bouncy
 Soft
 Above previous sites
 Refills when depressed
 Visible
 Has a large lumen
 Well supported
 Straight
 Easily palpable

47
 What veins should you avoid ?
 Thrombosed / sclerosed / fibrosed
 Inflamed / bruised
 Thin / Fragile
 Mobile
 Near bony prominences
 Areas or sites of infection, oedema or phlebitis
 Have undergone multiple previous punctures
 Do not use if patient has IV fluid in situ

48
 PROCEDURE

 Wash hands prepare equipment ANTT

 Remove the cannula from the packaging and check all parts are
operational
 Loosen the white cap and gently replace it
 Apply tourniquet
 Identify vein
 Clean the site over the vein with alcohol wipe, allow to dry

49
 PROCEDURE
 Remove tourniquet if not able to proceed
 Put on non-sterile gloves
 Re-apply the tourniquet, 7-10 cm above site
 Remove the protective sleeve from the needle taking care not to touch it at any time
 Hold the cannula in your dominant hand, stretch the skin over the vein to anchor the vein
with your non-dominant hand (Do not re palpate the vein)

50
 PROCEDURE
 Insert the needle (bevel side up) at an angle of 10-30o to the skin (this will depend on vein depth.)
 Observe for blood in the flashback chamber

51
PROCEDURE
 Lower the cannula slightly to ensure it enters the lumen and does not puncture exterior wall of the vessel

 Gently advance the cannula over the needle whilst withdrawing the guide, noting secondary flashback
along the cannula

 Release the tourniquet

 Apply gentle pressure over the vein (beyond the cannula tip) remove the white cap from the needle

52
PROCEDURE
 Remove the needle from the cannula and dispose of it into a sharps
container

 Attach the white lock cap

 Secure the cannula with an appropriate dressing

 Flush the cannula with 2-5 mls 0.9% Sodium Chloride or attach an IV
giving set and fluid

53
 COMPLICATION
 The intravenous (IV) cannula offers direct access to a patient's vascular system and provides a potential
route for entry of micro organisms into that system. These organisms can cause serious infection if they are
allowed to enter and proliferate in the IV cannula, insertion site, or IV fluid.

 IV-Site Infection: Does not produce much (if any) pus or inflammation at the IV site.  This is the most
common cannula-related infection, may be the most difficult to identify

54
 Cellulites:  Warm, red and often tender skin surrounding the site of cannula insertion; pus is rarely detectable.

 Infiltration or tissuing occurs when the infusion (fluid) leaks into the surrounding tissue. It is important to
detect early as tissue necrosis could occur – re-site cannula immediately

55
 Thrombolism / thrombophlebitis occur when a small clot becomes detached from the sheath of the cannula
or the vessel wall – prevention is the greatest form of defence. Flush cannula regularly and consider re-siting
the cannula if in prolonged use.

 Extravasation is the accidental administration of IV drugs into the surrounding tissue, because the needle has
punctured the vein and the infusion goes directly into the arm tissue. The leakage of high osmolarity solutions
or chemotherapy agents can result in significant tissue destruction, and significant complications

56
 Bruising commonly results from failed IV placement - particularly in the elderly and those on anticoagulant
therapy.

 Air embolism occurs when air enters the infusion line, although this is very rare it is best if we consider the
preventive measures – Make sure all lines are well primed prior to use and connections are secure

57
 Haematoma occurs when blood leaks out of the infusion site. The common cause of this is using cannula that
are not tapered at the distal end. It will also occur if on insertion the cannula has penetrated through the other
side of the vessel wall – apply pressure to the site for approximately 4 minutes and elevate the limb

 Phlebitis is common in IV therapy and can be cause in many ways. It is inflammation of a vein (redness and
pain at the infusion site) – prevention can be using aseptic insertion techniques, choosing the smallest gauge
cannula possible for the prescribed treatment, secure the cannula properly to prevent movement and carry out
regular checks of the infusion site.

58
TERIMAKASIH
1. Gahtan V, Costanza MJ, editors. Essentials of vascular surgery for the
general surgeon. Springer New York; 2015.
2. Bannon MP, Heller SF, Rivera M. Anatomic considerations for central
venous cannulation. Risk management and healthcare policy. 2011;4:27.
3. Akaraborworn O. A review in emergency central venous catheterization.
Chinese Journal of Traumatology. 2017 Jun 1;20(3):137-40.
4. Tse A, Schick MA. Central Line Placement. 2019.
5. Leib AD, England BS, Kiel J. Central Line. InStatPearls [Internet] 2019 Jun
16. StatPearls Publishing.
6. Reichman EF. Reichman's Emergency Medicine Procedures. McGraw Hill
Professional; 2018 Dec 25.