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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
causes of high CVP (6)
fluid overload heart failure pulm HTN tburg high intrathoracic pressure tricuspid/pulm stenosis/regurge
26
treatment of high CVP
fluid restriction diuretic inotrope (HF pts)
27
what happens during a valsalva maneuver
incr intrathoracic P decr venous return incr CVP
28
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
29
CVP waveform name
acxvy
30
a wave
end diastole atrial contraction
31
c wave
early systole ventricular contraction
32
x descent
mid systole atrial relaxation during ventricular systole
33
v wave
late systole blood filling in RA during relaxation
34
y descent
early diastole opening of tricuspid valve prior to atrial contraction
35
types of larger CVP waves
cannon A wave regurgitant V wave
36
cannon A wave
abnormally tall "a" wave on CVP waveform
37
regurgitant wave
abnormally tall "v" wave on CVP waveform
38
cannon "a" wave occurs when
incr in pressure in RA during atrial contraction
39
causes of cannon "a" wave
tricuspid stenosis complete heart block junctional rhythm
40
a regurgitant "v" wave occurs when
incr in pressure in RA during atrial relaxation period
41
cause of regurgitant "v" wave
tricuspid regurge - volume from ventricle backflows into RA during ventricular systole
42
what happens to CVP waveform during tricuspid regurge
no x descent elevated v wave
43
systole cvp waves
C X V
44
diastole cvp waves
Y A
45
central line complications (8)
1. infection 2. venous stenosis 3. arterial puncture 4. thrombosis 5. pneumothorax 6. ectopy 7. nerve injury 8. air embolism
46
which has a higher risk of infection central or arterial lines?
central lines
47
how do you rule out accidental arterial puncture?
color of blood transducing the blood pressure
48
how do you avoid carotid artery puncture
insert needle lateral to carotid pulse
49
what causes transient arrhythmias during insertion of central line?
selding wire irritating myocardium
50
what is the level when an air embolism can be fatal for an adult?
200-300 mL or 3-5 mL/kg
51
air embolism CV effects
decr CO interrupts pulmonary gas exchange
52
air embolism symptoms
1. hypotension 2. tachycardia 3. sudden etCO2 decr 4. incr PaCO2 5. sudden etN2 incr 6. cyanosis
53
air embolism risk factors
1. surgical site above level of heart -- sitting surgeries 2. central line placement
54
how to mitigate air embolism risk during central line insertion?
keep catheter as occluded as possible put pt in trendelenburg
55
air embolism diagnosis
TEE - gold std precordial doppler
56
most sensitive method for diagnosing air embolism
TEE
57
what indicates an air embolism on precordial doppler?
sporadic roaring sounds
58
in field avoidance cases, what method is used to diagnosis air embolism?
precordial doppler
59
air embolism treatment
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
what does jugular venous compression do?
prevents further air entrainment identifies open dural sinuses via retrograde flow
61
when should you be cautious about applying jugular venous compression?
with increased ICP or decreased CBF
62
easiest path to SVC (rank easiest to most difficult)
Easiest right IJ left subclavian left IJ right subclavian right/left EJ Difficult
63
IJ advantages
great us visualization easiest catheter pathway to right atrium
64
complication rate when using us with IJ central line placement
57% less complications w/us
65
IJ disadvantages | 4
close to carotid significant infection risk pneumothorax risk uncomfortable
66
EJ advantage
most superficial vein easy to cannulate
67
EJ disadvantage
tortuous path to SVC high infection risk
68
EJ clinical use
regular IV typically not used to start central line
69
subclavian advantage
lowest infection rate lowest DVT rate most comfortable
70
subclavian disadvantage
highest pneumothorax risk difficult to control bleeding pinch off syndrome
71
what increases the risk of pneumothorax in subclavian line placement?
mechanical ventilation hold ventilation during needle insertion
72
why is bleeding more difficult to control in subclavian placement?
vessel cant be compressed as much due to clavicle
73
pinch off syndrome
catheter compressed between clavicle and first rib
74
pinch off syndrome diagnosis
difficult flushing or aspiration based on arm position confirmed via xray
75
what is safer: axillary or subclavian placement?
axillary
76
lowest infection rate central line site
subclavian/axillary
77
axillary advantages over subclavian
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
Femoral central line landmarks
LATERAL Nerve Artery Vein Empty Lymphatics MEDIAL
79
femoral central line placement advantage
easier access site in emergency
80
femoral central line placement disadvantage
highest risk of infection risk of arterial puncture risk of VTE
81
how long should you leave a femoral central line in maximally?
24 hrs (replace with another line if needed)
82
triple lumen central line ports
1 distal 16ga brown lumen 2 proximal 18 g white/blue lumen
83
brown lumen size
16ga
84
triple lumen: brown lumen use
CVP
85
triple lumen: brown lumen is hooked up to
non-compliant transducer tubing
86
triple lumen: white/blue lumen uses
fluid boluses infusion line
87
triple lumen: white/blue lumen are connected to
IV tubing
88
double lumen central line ports
2 16ga ports distal = brown proximal = white
89
brown port is used for
CVP
90
white/blue port is used for
fluids infusion
91
double or triple lumen central line sizing
7 Fr
92
types of central lines that have an introducer port
8.5F percutaneous sheath introducer (PSI) double lumen 9F MAC catheter
93
introducer port is required to
float insert pacing wires insert pulmonary artery (swan ganz) catheter
94
introducer port advantage
larger line (8.5-9F)
95
introducer port disadvantage
less ports
96
ways to add more ports to central line
1. pulmonary artery (Swan ganz) catheter 2. companion catheter 3. single lumen infusion catheter
97
pulmonary artery catheter adds ___ ports
3 ports - CVP - infusions - pulm artery pressure
98
companion catheter
single or double lumen allows for infusions and/or CVP monitoring
99
single lumen infusion catheter (SLIC)
1 port for CVP monitoring
100
dialysis central line size
14F (or smaller)
101
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
102
dialysis central line lumens
1 draws blood to dialysis machine 1 reinfuses purified blood
103
long term therapy central line tyopes
PICC lines tunneled catheter
104
Peripherally Inserted Central Catheter (PICC) line
long catheter guided into SVC through the antecubital vein
105
PICC line lumens
single, double, or triple
106
PICC line flow rate
slow long catheter more resistance slow flow
107
tunneled central line
same placement as central line but uses a port placed in a surgical pocket beneath the skin
108
types of tunneled catheters
mediport/portacath broviac
109
which tunneled cathether has lower infection rate
mediport/portacath
110
which tunneled catheter is completely under the skin
mediport/portacath
111
how is a mediport accessed?
huber needle stick
112
how to prevent clot formation inside tunneled catheters?
heparin
113
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
114
what should you do before and after drug admin through tunneled catheter?
flush with LR or N/S
115
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Sp: PMI (18 decks)

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