5.

Placing the catheter, finding the vein :

a. Choose the appropriate catheter
b. Mark the length of catheter to achieve
the proper place
c. Attach the entry needle to a small 1-3ml
syringe and rinsed with hep/saline
solution
d. Once through the skin, apply a small
negative pressure to aid blood return as
the needle is advanced


e. When blood return is apparent, advance
the needle an additional 1-2mm until a
free flow of blood is obtained.
f. Use a 23-25G, 1.5inch needle as a finder
needle if difficulties appear, or change the
rolled towell with a smaller one, or
repositioned the patient
g. Inadvertent arterial puncture should be
suspected whenever the blood appears
redder or shows a pulsatile flow
h. Use non-Luer-Lock syringe
5. Placing the catheter, inserting the
catheter (Seldinger technic )
a. Detach the syringe carefully, once the
needle successfully enters the vessel
b. Occlude the needle lumen with the
thumb after the syringe is removed
c. Insert the guide wire, keep the proximal
end visible
d. Remove the entry needle and enlarge
the skin puncture site using a scalpel
blade (No.11). A stiff dilator might be
needed.
e. Place the catheter over the guide wire,
again, keep the proximal end of the wire
visible outside the catheter hub.
f. Advance the catheter with a steady
gentle pressure, and a slow, twisting
motion, until the expected length of the
catheter were inside the vessel
g. Ensure that the tip is properly positioned
by doing a radiograph.



Ensure that the
tip is properly
positioned by
doing a
radiograph.

Trouble shooting, guide wire insertion:
1. Remove guide wire if the guide wire does
not pass easily / with minimal resistance
2. Reconfirm the needle position
3. Redirect or rotate the needle bevel or
just be patient, wait untill the spasm is
gone
4. Reinsert the guide wire.
5. If there is a resistance during wire
removal, withdraw the needle and the
wire together immediately
Trouble shooting, catheter insertion
:
If resistance is met at this stage,
1. If fraying is present, change the
catheter
2. Repeat the scalpel incision
3. Use the stiff dilator to create a
tract
Arterial blood ?:
Colour
Pulsation
Blood Gas
Analysis
Pressure wave

6. Securing and Dressing the
catheter
a. Securing with stiching
b. Povidone-iodine
c. Sterile gauze and tape
vs transparent

7. Documentation
a. Date and time of insertion
b. Catheter type, gauge, length
c. Any complication encountered
d. Catheter placement confirmation
e. The patients condition

1. Clean surgical gloves from powder
2. Use the smallest catheter to fit the
indication
3. Do not take the catheter out of the
additional sterile plastic sack (sterility
sleeve?)
4. Reconfirm catheter tip position
regularly
5. Do not use alcohol or aceton to clean
6. In multilumen catheters,
i. End hole : blood products / CVP monitoring
ii. Side hole : medication, TPN, blood sampling

7. Do saline flushing when changing
infusate solution
8. Do not secure the catheter too tight, as
thrombosis will easily occur







Thank you for
Your attention
Sumsum tulang panjang dapat
berfungsi sebagai vena yang tidak
pernah kolaps.
Darah mengalir dari sinusoid vena ke
kanal vena sentral dan selanjutnya
melalui vena emisari / nutrisi masuk
ke sirkulasi sentral.
Absorbsi dlm sumsum tlg cukup cepat
wlp tentu tidak secepat akses
perifer/sentral ( 11-45ml/menit)
AKSES INTRAOSSEOUS
AKSES INTRAOSSEOUS
Lokasi :
1. Mediocaudal Tuberositas Tibia, kira-kira 2cm. ( smp 3-4thn)
2. Cranial malleolus medial , kira-kira 2 cm.(diatas 3-4thn)
3. Distal femur, 1-2cm diatas patela.
Tibia proximal
Indikasi : Henti jantung paru dan syok
Indikasi kontra : recent fracture, osteogenesis
imperfecta, osteoporosis.
Indikasi Kontra relatif : selulitis dan luka bakar
Akses Intraosseous
Aspirat dapat untuk pemeriksaan elektrolit, glukosa, ureum , kreatinin.
Juga untuk sample kros-darah. Tapi tidak untuk darah lengkap.
Komplikasi : tergantung lama penggunaan, usahakan < 24jam. :
furunkulosis, osteokondritis, osteomielitis,selulitis , abses subkutan,
sindrom ruang, emboli lemak, kerusakan tulang, sepsis dan bakteriemia.
Alat :
Jarum khusus dengan mandrijn
Jarum untuk pungsi sum-sum tulang
Jarum pungsi lumbal yang terbesar
Jarum no. 16
Akses Intraosseous