15. Central Lines Flashcards
central line
larger bore
longer IV catheter
inserted into lg vein
most common central line sites
IJ
EJ
subclavian
femoral
what is the “correct placement” of a central line
distal tip of catheter at junction of SVC and RA
catheter distal tip too high
increased risk of thrombus
catheter distal tip too low
increased risk of arrhythmia
central line indications (8)
- fluid/blood admin at faster rate
- IV access after failed peripheral attempts
- CVP monitoring
- pulmonary artery (swan ganz catheter)
- med admin f/peripherally CI meds (epi/NE, etc)
- temporary emergency hemodialysis
- temporary transvenous pacing wires
- air embolism aspiration
most common vein used for IV access via central line
EJ
long term central line indications
- chemo
- long term abx
- total parenteral nutrition (TPN)
venous return
amount of venous blood returning to the RA of the heart
venous return is associated with
CVP
adequate venous return
normal CVP
decreased venous return
low CVP
factor that decrease venous return
hypovolemia
sitting
reverse trendelenburg
high intrathoracic pressure
vasodilation
causes of high intrathoracic pressure
PPV
PEEP
tension pneumothorax
how does high intrathoracic pressure decr venous return
pressure on central veins
incr resistance
decr venous return
how does vasodilation cause decr venous return
vasodilation causes blood to pool in legs
decr venous return
factors that increase venous return
- fluid admin to hypovolemic pt
- negative intrathoracic pressure
- trendelenburg
- lithotomy
CVP
blood pressure inside a central vein
normal CVP
5-12 mmHg
why is CVP monitoring valuable
- assess pt volume status
- assess pt venous return
- diagnose RHF
- diagnose pulm HTN
low CVP in supine pt could mean
hypovolemia
and/or
decr venous return
RHF and pulm HTN can cause
high CVP
causes of low CVP
hypovolemia
reverse tburg
sitting/beach chair
vasodilation
treatment of low CVP
volume resuscitation
causes of high CVP (6)
fluid overload
heart failure
pulm HTN
tburg
high intrathoracic pressure
tricuspid/pulm stenosis/regurge
treatment of high CVP
fluid restriction
diuretic
inotrope (HF pts)
what happens during a valsalva maneuver
incr intrathoracic P
decr venous return
incr CVP
how does high intrathoracic pressure incr CVP
high intrathoracic pressure decr venous return from legs and head
decr venous return from head causes blood pooling
incr CVP
CVP waveform name
acxvy
a wave
end diastole
atrial contraction
c wave
early systole
ventricular contraction
x descent
mid systole
atrial relaxation during ventricular systole
v wave
late systole
blood filling in RA during relaxation
y descent
early diastole
opening of tricuspid valve prior to atrial contraction
types of larger CVP waves
cannon A wave
regurgitant V wave
cannon A wave
abnormally tall “a” wave on CVP waveform
regurgitant wave
abnormally tall “v” wave on CVP waveform
cannon “a” wave occurs when
incr in pressure in RA during atrial contraction
causes of cannon “a” wave
tricuspid stenosis
complete heart block
junctional rhythm
a regurgitant “v” wave occurs when
incr in pressure in RA during atrial relaxation period
cause of regurgitant “v” wave
tricuspid regurge
- volume from ventricle backflows into RA during ventricular systole
what happens to CVP waveform during tricuspid regurge
no x descent
elevated v wave
systole cvp waves
C
X
V
diastole cvp waves
Y
A
central line complications (8)
- infection
- venous stenosis
- arterial puncture
- thrombosis
- pneumothorax
- ectopy
- nerve injury
- air embolism
which has a higher risk of infection central or arterial lines?
central lines
how do you rule out accidental arterial puncture?
color of blood
transducing the blood pressure
how do you avoid carotid artery puncture
insert needle lateral to carotid pulse
what causes transient arrhythmias during insertion of central line?
selding wire irritating myocardium
what is the level when an air embolism can be fatal for an adult?
200-300 mL
or 3-5 mL/kg
air embolism CV effects
decr CO
interrupts pulmonary gas exchange
air embolism symptoms
- hypotension
- tachycardia
- sudden etCO2 decr
- incr PaCO2
- sudden etN2 incr
- cyanosis
air embolism risk factors
- surgical site above level of heart
– sitting surgeries - central line placement
how to mitigate air embolism risk during central line insertion?
keep catheter as occluded as possible
put pt in trendelenburg
air embolism diagnosis
TEE - gold std
precordial doppler
most sensitive method for diagnosing air embolism
TEE
what indicates an air embolism on precordial doppler?
sporadic roaring sounds
in field avoidance cases, what method is used to diagnosis air embolism?
precordial doppler
air embolism treatment
- flood field w/saline
- jugular venous compression
- 100% O2
- left lateral trendelenburg
- give vasopressors, inotropes to stabilize BP
- start a central line and aspirate air out
- give volume to incr CVP
what does jugular venous compression do?
prevents further air entrainment
identifies open dural sinuses via retrograde flow
when should you be cautious about applying jugular venous compression?
with increased ICP or decreased CBF
easiest path to SVC (rank easiest to most difficult)
Easiest
right IJ
left subclavian
left IJ
right subclavian
right/left EJ
Difficult
IJ advantages
great us visualization
easiest catheter pathway to right atrium
complication rate when using us with IJ central line placement
57% less complications w/us
IJ disadvantages
4
close to carotid
significant infection risk
pneumothorax risk
uncomfortable
EJ advantage
most superficial vein
easy to cannulate
EJ disadvantage
tortuous path to SVC
high infection risk
EJ clinical use
regular IV
typically not used to start central line
subclavian advantage
lowest infection rate
lowest DVT rate
most comfortable
subclavian disadvantage
highest pneumothorax risk
difficult to control bleeding
pinch off syndrome
what increases the risk of pneumothorax in subclavian line placement?
mechanical ventilation
hold ventilation during needle insertion
why is bleeding more difficult to control in subclavian placement?
vessel cant be compressed as much due to clavicle
pinch off syndrome
catheter compressed between clavicle and first rib
pinch off syndrome diagnosis
difficult flushing or aspiration based on arm position
confirmed via xray
what is safer: axillary or subclavian placement?
axillary
lowest infection rate central line site
subclavian/axillary
axillary advantages over subclavian
- easier to visualize w/us
- less risk of arterial puncture
- less risk of pneumothorax
- less risk of catheter pinch off
- easily able to apply pressure due to arterial puncture
Femoral central line landmarks
LATERAL
Nerve
Artery
Vein
Empty
Lymphatics
MEDIAL
femoral central line placement advantage
easier access site in emergency
femoral central line placement disadvantage
highest risk of infection
risk of arterial puncture
risk of VTE
how long should you leave a femoral central line in maximally?
24 hrs
(replace with another line if needed)
triple lumen central line ports
1 distal 16ga brown lumen
2 proximal 18 g white/blue lumen
brown lumen size
16ga
triple lumen: brown lumen use
CVP
triple lumen: brown lumen is hooked up to
non-compliant transducer tubing
triple lumen: white/blue lumen uses
fluid boluses
infusion line
triple lumen: white/blue lumen are connected to
IV tubing
double lumen central line ports
2 16ga ports
distal = brown
proximal = white
brown port is used for
CVP
white/blue port is used for
fluids
infusion
double or triple lumen central line sizing
7 Fr
types of central lines that have an introducer port
8.5F percutaneous sheath introducer (PSI)
double lumen 9F MAC catheter
introducer port is required to
float insert pacing wires
insert pulmonary artery (swan ganz) catheter
introducer port advantage
larger line (8.5-9F)
introducer port disadvantage
less ports
ways to add more ports to central line
- pulmonary artery (Swan ganz) catheter
- companion catheter
- single lumen infusion catheter
pulmonary artery catheter adds ___ ports
3 ports
- CVP
- infusions
- pulm artery pressure
companion catheter
single or double lumen
allows for infusions and/or CVP monitoring
single lumen infusion catheter (SLIC)
1 port for CVP monitoring
dialysis central line size
14F (or smaller)
dialysis central line
short term solution until permanent dialysis access can be obtained
treatment for acute problem in pt that doesnt need permanent dialysis access
dialysis central line lumens
1 draws blood to dialysis machine
1 reinfuses purified blood
long term therapy central line tyopes
PICC lines
tunneled catheter
Peripherally Inserted Central Catheter (PICC) line
long catheter guided into SVC through the antecubital vein
PICC line lumens
single, double, or triple
PICC line flow rate
slow
long catheter
more resistance
slow flow
tunneled central line
same placement as central line but uses a port placed in a surgical pocket beneath the skin
types of tunneled catheters
mediport/portacath
broviac
which tunneled cathether has lower infection rate
mediport/portacath
which tunneled catheter is completely under the skin
mediport/portacath
how is a mediport accessed?
huber needle stick
how to prevent clot formation inside tunneled catheters?
heparin
what should you do prior to administering meds or fluids into tunneled catheter?
aspirate 10mL of blood to avoid pt receiving large dose of heparin
what should you do before and after drug admin through tunneled catheter?
flush with LR or N/S
