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Sp: PMI > 15. Central Lines > Flashcards

15. Central Lines Flashcards

1
Q

central line

A

larger bore
longer IV catheter
inserted into lg vein

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2
Q

most common central line sites

A

IJ
EJ
subclavian
femoral

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3
Q

what is the “correct placement” of a central line

A

distal tip of catheter at junction of SVC and RA

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4
Q

catheter distal tip too high

A

increased risk of thrombus

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5
Q

catheter distal tip too low

A

increased risk of arrhythmia

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6
Q

central line indications (8)

A
  1. fluid/blood admin at faster rate
  2. IV access after failed peripheral attempts
  3. CVP monitoring
  4. pulmonary artery (swan ganz catheter)
  5. med admin f/peripherally CI meds (epi/NE, etc)
  6. temporary emergency hemodialysis
  7. temporary transvenous pacing wires
  8. air embolism aspiration
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7
Q

most common vein used for IV access via central line

A

EJ

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8
Q

long term central line indications

A
  1. chemo
  2. long term abx
  3. total parenteral nutrition (TPN)
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9
Q

venous return

A

amount of venous blood returning to the RA of the heart

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10
Q

venous return is associated with

A

CVP

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11
Q

adequate venous return

A

normal CVP

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12
Q

decreased venous return

A

low CVP

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13
Q

factor that decrease venous return

A

hypovolemia
sitting
reverse trendelenburg
high intrathoracic pressure
vasodilation

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14
Q

causes of high intrathoracic pressure

A

PPV
PEEP
tension pneumothorax

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15
Q

how does high intrathoracic pressure decr venous return

A

pressure on central veins
incr resistance
decr venous return

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16
Q

how does vasodilation cause decr venous return

A

vasodilation causes blood to pool in legs
decr venous return

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17
Q

factors that increase venous return

A
  1. fluid admin to hypovolemic pt
  2. negative intrathoracic pressure
  3. trendelenburg
  4. lithotomy
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18
Q

CVP

A

blood pressure inside a central vein

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19
Q

normal CVP

A

5-12 mmHg

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20
Q

why is CVP monitoring valuable

A
  1. assess pt volume status
  2. assess pt venous return
  3. diagnose RHF
  4. diagnose pulm HTN
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21
Q

low CVP in supine pt could mean

A

hypovolemia
and/or
decr venous return

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22
Q

RHF and pulm HTN can cause

A

high CVP

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23
Q

causes of low CVP

A

hypovolemia
reverse tburg
sitting/beach chair
vasodilation

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24
Q

treatment of low CVP

A

volume resuscitation

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25
Q

causes of high CVP (6)

A

fluid overload
heart failure
pulm HTN
tburg
high intrathoracic pressure
tricuspid/pulm stenosis/regurge

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26
Q

treatment of high CVP

A

fluid restriction
diuretic
inotrope (HF pts)

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27
Q

what happens during a valsalva maneuver

A

incr intrathoracic P
decr venous return
incr CVP

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28
Q

how does high intrathoracic pressure incr CVP

A

high intrathoracic pressure decr venous return from legs and head

decr venous return from head causes blood pooling

incr CVP

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29
Q

CVP waveform name

A

acxvy

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30
Q

a wave

A

end diastole
atrial contraction

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31
Q

c wave

A

early systole
ventricular contraction

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32
Q

x descent

A

mid systole
atrial relaxation during ventricular systole

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33
Q

v wave

A

late systole
blood filling in RA during relaxation

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34
Q

y descent

A

early diastole
opening of tricuspid valve prior to atrial contraction

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35
Q

types of larger CVP waves

A

cannon A wave
regurgitant V wave

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36
Q

cannon A wave

A

abnormally tall “a” wave on CVP waveform

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37
Q

regurgitant wave

A

abnormally tall “v” wave on CVP waveform

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38
Q

cannon “a” wave occurs when

A

incr in pressure in RA during atrial contraction

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39
Q

causes of cannon “a” wave

A

tricuspid stenosis
complete heart block
junctional rhythm

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40
Q

a regurgitant “v” wave occurs when

A

incr in pressure in RA during atrial relaxation period

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41
Q

cause of regurgitant “v” wave

A

tricuspid regurge
- volume from ventricle backflows into RA during ventricular systole

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42
Q

what happens to CVP waveform during tricuspid regurge

A

no x descent
elevated v wave

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43
Q

systole cvp waves

A

C
X
V

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44
Q

diastole cvp waves

A

Y
A

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45
Q

central line complications (8)

A
  1. infection
  2. venous stenosis
  3. arterial puncture
  4. thrombosis
  5. pneumothorax
  6. ectopy
  7. nerve injury
  8. air embolism
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46
Q

which has a higher risk of infection central or arterial lines?

A

central lines

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47
Q

how do you rule out accidental arterial puncture?

A

color of blood
transducing the blood pressure

48
Q

how do you avoid carotid artery puncture

A

insert needle lateral to carotid pulse

49
Q

what causes transient arrhythmias during insertion of central line?

A

selding wire irritating myocardium

50
Q

what is the level when an air embolism can be fatal for an adult?

A

200-300 mL
or 3-5 mL/kg

51
Q

air embolism CV effects

A

decr CO
interrupts pulmonary gas exchange

52
Q

air embolism symptoms

A
  1. hypotension
  2. tachycardia
  3. sudden etCO2 decr
  4. incr PaCO2
  5. sudden etN2 incr
  6. cyanosis
53
Q

air embolism risk factors

A
  1. surgical site above level of heart
    – sitting surgeries
  2. central line placement
54
Q

how to mitigate air embolism risk during central line insertion?

A

keep catheter as occluded as possible
put pt in trendelenburg

55
Q

air embolism diagnosis

A

TEE - gold std
precordial doppler

56
Q

most sensitive method for diagnosing air embolism

A

TEE

57
Q

what indicates an air embolism on precordial doppler?

A

sporadic roaring sounds

58
Q

in field avoidance cases, what method is used to diagnosis air embolism?

A

precordial doppler

59
Q

air embolism treatment

A
  1. flood field w/saline
  2. jugular venous compression
  3. 100% O2
  4. left lateral trendelenburg
  5. give vasopressors, inotropes to stabilize BP
  6. start a central line and aspirate air out
  7. give volume to incr CVP
60
Q

what does jugular venous compression do?

A

prevents further air entrainment
identifies open dural sinuses via retrograde flow

61
Q

when should you be cautious about applying jugular venous compression?

A

with increased ICP or decreased CBF

62
Q

easiest path to SVC (rank easiest to most difficult)

A

Easiest
right IJ
left subclavian
left IJ
right subclavian
right/left EJ
Difficult

63
Q

IJ advantages

A

great us visualization
easiest catheter pathway to right atrium

64
Q

complication rate when using us with IJ central line placement

A

57% less complications w/us

65
Q

IJ disadvantages

4

A

close to carotid
significant infection risk
pneumothorax risk
uncomfortable

66
Q

EJ advantage

A

most superficial vein
easy to cannulate

67
Q

EJ disadvantage

A

tortuous path to SVC
high infection risk

68
Q

EJ clinical use

A

regular IV

typically not used to start central line

69
Q

subclavian advantage

A

lowest infection rate
lowest DVT rate
most comfortable

70
Q

subclavian disadvantage

A

highest pneumothorax risk
difficult to control bleeding
pinch off syndrome

71
Q

what increases the risk of pneumothorax in subclavian line placement?

A

mechanical ventilation

hold ventilation during needle insertion

72
Q

why is bleeding more difficult to control in subclavian placement?

A

vessel cant be compressed as much due to clavicle

73
Q

pinch off syndrome

A

catheter compressed between clavicle and first rib

74
Q

pinch off syndrome diagnosis

A

difficult flushing or aspiration based on arm position

confirmed via xray

75
Q

what is safer: axillary or subclavian placement?

A

axillary

76
Q

lowest infection rate central line site

A

subclavian/axillary

77
Q

axillary advantages over subclavian

A
  1. easier to visualize w/us
  2. less risk of arterial puncture
  3. less risk of pneumothorax
  4. less risk of catheter pinch off
  5. easily able to apply pressure due to arterial puncture
78
Q

Femoral central line landmarks

A

LATERAL
Nerve
Artery
Vein
Empty
Lymphatics
MEDIAL

79
Q

femoral central line placement advantage

A

easier access site in emergency

80
Q

femoral central line placement disadvantage

A

highest risk of infection
risk of arterial puncture
risk of VTE

81
Q

how long should you leave a femoral central line in maximally?

A

24 hrs
(replace with another line if needed)

82
Q

triple lumen central line ports

A

1 distal 16ga brown lumen
2 proximal 18 g white/blue lumen

83
Q

brown lumen size

A

16ga

84
Q

triple lumen: brown lumen use

A

CVP

85
Q

triple lumen: brown lumen is hooked up to

A

non-compliant transducer tubing

86
Q

triple lumen: white/blue lumen uses

A

fluid boluses
infusion line

87
Q

triple lumen: white/blue lumen are connected to

A

IV tubing

88
Q

double lumen central line ports

A

2 16ga ports
distal = brown
proximal = white

89
Q

brown port is used for

A

CVP

90
Q

white/blue port is used for

A

fluids
infusion

91
Q

double or triple lumen central line sizing

A

7 Fr

92
Q

types of central lines that have an introducer port

A

8.5F percutaneous sheath introducer (PSI)
double lumen 9F MAC catheter

93
Q

introducer port is required to

A

float insert pacing wires
insert pulmonary artery (swan ganz) catheter

94
Q

introducer port advantage

A

larger line (8.5-9F)

95
Q

introducer port disadvantage

A

less ports

96
Q

ways to add more ports to central line

A
  1. pulmonary artery (Swan ganz) catheter
  2. companion catheter
  3. single lumen infusion catheter
97
Q

pulmonary artery catheter adds ___ ports

A

3 ports
- CVP
- infusions
- pulm artery pressure

98
Q

companion catheter

A

single or double lumen
allows for infusions and/or CVP monitoring

99
Q

single lumen infusion catheter (SLIC)

A

1 port for CVP monitoring

100
Q

dialysis central line size

A

14F (or smaller)

101
Q

dialysis central line

A

short term solution until permanent dialysis access can be obtained

treatment for acute problem in pt that doesnt need permanent dialysis access

102
Q

dialysis central line lumens

A

1 draws blood to dialysis machine
1 reinfuses purified blood

103
Q

long term therapy central line tyopes

A

PICC lines
tunneled catheter

104
Q

Peripherally Inserted Central Catheter (PICC) line

A

long catheter guided into SVC through the antecubital vein

105
Q

PICC line lumens

A

single, double, or triple

106
Q

PICC line flow rate

A

slow
long catheter
more resistance
slow flow

107
Q

tunneled central line

A

same placement as central line but uses a port placed in a surgical pocket beneath the skin

108
Q

types of tunneled catheters

A

mediport/portacath
broviac

109
Q

which tunneled cathether has lower infection rate

A

mediport/portacath

110
Q

which tunneled catheter is completely under the skin

A

mediport/portacath

111
Q

how is a mediport accessed?

A

huber needle stick

112
Q

how to prevent clot formation inside tunneled catheters?

A

heparin

113
Q

what should you do prior to administering meds or fluids into tunneled catheter?

A

aspirate 10mL of blood to avoid pt receiving large dose of heparin

114
Q

what should you do before and after drug admin through tunneled catheter?

A

flush with LR or N/S

115
Q
A
116
Q
A

Sp: PMI (18 decks)

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