Sheath introducer

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]

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

External Links

References

  1. 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.
  2. Graham, A.S., et al. Central Venous Catheterization. N Engl J Med 2007;356:e21
  3. Fisher NC, Mutimer DJ. Central venous cannulation in patients with liver disease and coagulopathy—a prospective audit. Intens Care Med 1999; 25:5
  4. Morado M.et al. Complications of central venous catheters in patients with haemophilia and inhibitors. Haemophilia 2001; 7:551–556