8. Tubes/Line positions in DCCM/CVICU Flashcards
what are 3 reasons for learning correct tub/line positions and pathologies
MITs are first to view image
misplaced tubes/lines and pathologies can be dealt with sooner before they become life threatening or cause further problems
patients in ICU are critically ill so any further complication could be life threatening or extend their stay
what does an endotracheal tube do
endotracheal intubation keeps airway open and protected to give O2/medicine/anesthesia
what does an endotracheal tube act as
acts as conduit between airway and ventilator
what does the cuff of an endotracheal tube do inflated to exact pressure and what does it prevent
seals trachea for positive pressure ventilation and prevents aspiration
what are 5 types of endotracheal tube
oral/nasal
cuffed/uncuffed
double lumen endotracheal tube
what feature of endotracheal tubes allow you to know how far to insert
they are all graduated with measurements
endotracheal tubes are inserted past where
past vocal chords
where does the pilot balloon of endotracheal tubes lie
outside of patient
what does the pilot balloon of endotracheal tubes do
indicates what the pressure is of the cuff inside the patient
the cuff of the endotracheal tube on the distal end near tube is inflated at exact pressure to seal what structure and what can it do to the image xrayed
seals trachea
left on chest so valve and spring looks like artifact on xray so need to get it out of the way
what happens if the pressure is too low inside endotracheal tubes
secretions can bypass cuff and get gurgling noise
what happens if the pressure is too high inside endotracheal tubes
can damage vascular structure to trachea
what would happen if you get positive pressure ventilation off ventilator and it didnt have a cuff
a lot pressure would come back out of airways and gas exchange wont happen and wouldn’t get inflation of chest to produce gas exchange
how do endotracheal tubes protect airways if patient vomits
balloon prevents vomit going into lungs
when intubating patient with endotracheal tube what is used to visualize vocal cords
visualize vocal cords with laryngoscope with measurements on side of tube so can slip it down to desired measurement so end of ET tube is at correct place in trachea and not misplaced tube
where does the carina lie
between T5-7
what bronchus is more vertical and how is this relevant for misplaced tubes
right main bronchus is more vertical than left so misplaced tube often goes down right main bronchus and can block off left vein so can get collapse of left lung or part of the lung and depending on how far they place it can also get collapse of right upper lobe
what is the correct position for endotracheal tubes tips
min 2cm, max 4cm from carina
ideal position is 3cm above carina
when you are assessing positioning of tube what position should the head be in and why
Make sure head is in neutral position when assessing positioning of tube as if its hyper flexed or extended can move placement of tube
what is a double lumen ETT used for
to separate the right lung from the left lung to avoid spillage of blood/pus to unaffected lung and ventilates one lung while they operate on other lung
when are double lumen ETT used
2 situations
some thoracic surgeries to collapse one lung and ventilate the remaining lung
or to ventilate each lung independently at different rates inflation pressure or tidal volumes
in a double lumen ETT which lung is operated on
operate on the one that is not intubated and can collapse down
what happens if the ETT is placed too high
dangerous as its close to the vocal chords and could slip out and be extravated
why do you want to get some neck in ICU patient image to assess position of ETT
as it may be placed too high near vocal chords
which main bronchus is the mispositioned ETT more likely to go down and why
right as its more vertical than the left
what could malpositioned ETT do to the lung lobe
lung lobe could collapse
what are 5 indications/situations that you should do a tracheotomy
airway obstruction
need for prolonged intubation
inability to intubate with need for GA
adjunct to major head and neck surgery/trauma management
airway protection (neurologic diseases, traumatic brain injury)
mechanical ventilation up to how many days may be endotracheally intubated
up to 10 days
what is favored if mechanical ventilation predicted for greater than 21 days
tracheostomy
how is the tracheostomy tube different from a ETT
length and shape is different as the tracheostomy tube is shorter and smaller
where is tracheostomy tube located
between the 2nd and 3rd tracheal rings
what is used to secure the tracheostomy tube
tape/flap attachment on the outside
what is done when the tracheostomy tube is taken out
put gauze swab to protect airway but it seals over itself in a few hours
where does the tracheostomy tube tip lie beteween
midway or 2/3 between stoma and carina
what are 2 types of Central venous catheters
tunneled and non tunnelled
when are tunneled Central venous catheters used
longer duration
what are 3 types of tunnelled Central venous catheters
hickman
groshong
portacath
when are non tunnelled Central venous catheters used
temporary use
such as access lines to administer drugs and fluids
what are 2 types of non tunnelled Central venous catheters
CVL and PICC lines
non tunnelled Central venous catheter lines cannulate where
the jugular vein in the neck straight down to SVC
tunnelled Central venous catheter lines cannulate where
usually cannulate right/left subclavian vein in the neck in surgery and distal end will go into the SVC and the other end will be tunneled under the patients tissue and will come out some distance away from operation location
how long can tunnelled Central venous catheter lines stay in for
as everything will be kept clean under the skin and just the port will come out of skin it can stay in for ages even years
where is an alternate area for the cannulation of the Central venous catheter not in the neck region
femoral vein in groin
what is the common access site for CVL
usually internal jugular vein gets cannulated and goes straight down to SVC
what joint to form the innominate veins
internal jugular vein and subclavian vein
what do the 2 innominate veins join to form
SVC
in what situation do you want lines in the right atrium
only for vascular catheter
what are 5 indications for CVL insertions
large venous access for prolonged intravenous therapies
used to administer medication/fluids
obtain blood tests - central venous O2 saturations
administer fluid/blood products for large volume resuscitation
measure central venous pressure
how man ports can non tunneled CVC have
single
double
triple
quadruple
what will happen to drugs that arent compatible if they go down the same same port
will crystalize
why dont drugs have interactions in multiport non tunneled CVC
when it gets into distal end there is a high blood flow so little chances the drugs will mix and will be distributed systemically very quickly
what are syringe pumps used for
different drugs are administered through syringe pumps to CVC as some drugs cant be mixed together so are administered through different ports of CVC
what are PICC lines
peripherally inserted central catheters
are PICC lines tunneled or non tunneled
non tunneled
where are the 3 locations that PICC lines are be placed in
ICU
PACU
radiology
what are 4 instances PICC lines are used
chemotherapy
parenteral nutrition
infection treatment (eg long term antibiotics)
other medication
what does PICC lines allow patients to do at home
allows them to go home after insertion and self administer drugs
are PICC lines diameters large or small
small
some medications will block PICC so what else is used instead
Hickman catheter used instead
what is the correct placement of right CVL
in lower SVC before the right atrium
at the level carina
what is the orientation of the tip of the CVL when inserted as a left sided CVL why
parallel to wall of SVC
as its pulsating and can perforate the wall so want tip either further back in the innominate or push through down into SVC (to prevent perforation of the wall)
does a LT or RT CVL require a longer catheter and why
left side CVL needs longer catheter due to increased distance to the SVC
what is the correct placement of left CVL
can have tip below the level of the carina
which 4 vessels can misplaced CVLs get into instead of going down SVC
internal jugular
innominate vein
opposite subclavian
right atrium
if the subclavian CVL line is placed too deep under the clavicle what could happen
could puncture the lung resulting in pneumothorax
what is a vascular catheter
hemodialysis catheter
large calibre catheter used for dialysis in ICU
where is the tip of the vascular catheter placed why in there
into proximal part of Right atrium where there is high blood flow
are hemodialysis catheters large/small diameter and why
large diameter to provide high flow
what are the 3 types of tunneled lines
hickmans
groshong
portacath
what are the 7 reasons tunneled lines are used
long term therapy chemotherapy blood transfusion parental nutrition infection treatment infection treatment other medications
what is cannulated for tunneled CVC
subclavian vein
tunneled CVC are inserted under what conditions and how are they imaged
inserted under strict sterile conditions in the OR
imaged after placement using II and have a CXR in PACU
how is the CVC placed in a tunneled line
placed through the insertion site then tunneled under the skin exiting away from the insertion site
how are tunneled lines inserted from cannulation site to exit site
Cannulate subclavian and feed catheter into the SVC
use forceps to push the rest down under the skin
they exit out under the skin away from operation site
what will you see under the skin in a portacath and what can you feel
under skin so will see a bulge under the skin
can feel circumference of port with knobbly bits
where are injections made in a portacath
in the middle
how much of the portacath is under the skin
completely under the skin
how long can portacath CVCs stay under the skin
stay in up to 5years
how are injections made with a portacath CVC
injections are made through the skin into the port
ports for portacath CVCs can be accessed up to how many times
up to 2000 times
why can the tip of a portacath CVC block and how can this be studied
tip of portacath can block due to a fibrin blood clot
can be studied in fluro using DSA watching the flow at the tip
how does the portacath CVC allow injection but prevent withdrawl
Can inject medication but cant withdraw blood from it as it has a clot that acts as a flap
Allows injection into blood but can aspirate and block tube when withdrawing
how is a groshong catheter’s tip different from other open ended catheters
has a closed rounded tip
the valve in a groshong catheter does what during infusion and aspiration and when its not being accessed
valve in side wall opens outwards during infusion and inwards during aspiration
valve remains closed when not being accessed
the groshong catheter requires flushing with what
what doesnt it need flushing with and why
flush with saline
not heparin because of the valve
what is a hickman CVC
tunneled small bore catheter used for infusion of antibiotics, chemotherapy and nutritional supplements
why is a hickman CVC used instead of a PICC line sometimes
because of the medication being infused as it wont block as easily as a PICC
what has a Swan Ganz catheter have at the tip
balloon and sensor
where does the Swan Ganz catheter normally lie
in the right atrium
what is a Swan Ganz catheter also known as
pulmonary artery catheter
what does a Swan Ganz catheter do - what are its 3 functions
measures pressures in the right heart chamber
estimates pressures in left heart chambers
measures CO by thermodilution technique (eg L/min)
basically monitors heart function and blood flow and pressures in heart
what is the Swan Ganz catheter used to assess in a patient
assess hemodynamic state of patient
what does Swan Ganz catheters give info to assess
assesses what 4 things
heart failure
sepsis
monitor therapy (ie fluid balance patients and not fluid overload them causing pulmonary edema)
evaluates effects of drugs
what is the path of a Swan Ganz catheter
through jugular vein -> SVC -> pulmonary valve -> pulmonary trunk
the pressures detected along the path of a Swan Ganz catheter shows what
pressures change showing what chamber of the heart your in
which pulmonary branch does the Swan Ganz catheter normally go in and can it go in the other
usually right pulmonary branch but can also go into left
where should the tip of the Swan Ganz catheter be
no further than the left/right main bronchus
or within 2cm of hilar region
when tip of the Swan Ganz catheter is in the pulmonary artery what happens next
When tip is in pulm artery it can measure that areas pressure and they can also blow a balloon up and its called a wedge pressure and with high blood flow the balloon will be taken further into the pulmonary tree where it gets smaller and cant go further and sensor says theres no blood flow and measure BP and this is equivalent to the left atrial pressure
what is a danger of the swan ganz catheter being taken into the pulmonary tree
danger is leaving it in wedge pressure
what is the wedge pressure when a swan ganz catheter is used
balloon will be taken further into the pulmonary tree from pulmonary artery where it gets smaller and cant go further and sensor says theres no blood flow and measure BP and this is equivalent to the left atrial pressure
when inserted the PA catheter generally lies in the ___ branch of the ___ __ but can equally lie in the ___ branch
lies in the right branch of the pulmonary artery but can equally lie in the left branch
at what times is the swan ganz catheter left in wedge position
the PA catheter is only left in wedged position with balloon inflated momentarily while the PAWP is obtained
why is it dangerous to leave the swan ganz catheter wedged
as it occludes the artery and its pulsating tip can erode through the wall of the vessel and cause pulmonary infarction (block blood supply to that part of the lung) or pulmonary artery rupture
the pulmonary artery wedge pressure indirectly measures what pressure
left atrium pressure
what is needed of the PA catheter is knotted
bedside fluoroscopy is sometimes needed to untangle the PA catheter or IR is involved
what are the 3 components of a correctly placed PA catheter
no kinks/coil/knots in the RA or RV
tip no further than the left or right main bronchus
tip within 2cm of the hilum
what are indications for insertion of a pleural or mediastinal drain
remove air/blood/fluid from the pleural space and mediastinum
what do pleural or mediastinal drains allow
allows expansion of lungs and restoration of negative pressure to the thoracic cavity
what does the underwater seal of the pleural or mediastinal drains do
under water seal prevents backflow of air or fluid into pleural cavity
what are the 5 conditions for requiring a chest drain
collapsed lung (eg pneumothorax)
lung infection
bleeding around lung
fluid buildup (eg cancer, pneumonia)
surgery - especially lung, heart or oesophageal
why do you not lift the underwater drain higher than level of bed
as fluid can drain back into pleural cavity or mediastinum
the tip of the chest drain should lie where
above diaphragm inside the rib cage and superimposed over the lung
where should the side holes of the chest drain be inside
insider pleural cavity
what do broad drains have
radiopaque lines in them
what are at the end of the underwater chest drains that collects the fluid and what do they do
underwater chest drain bottles
they prevent a backflow of fluid or air back into the pleural cavity
what are pigtail drains inserted to target
target loculated collections
are foley type mediastinal drains seen on CXR, why?
no as they are less radiopaque and have no opaque marker
what are intra-aortic balloon or intra-aortic counter pulsation device do
specialized arterial catheter which has a helium filled balloon
how and where is the intra-aortic balloon or intra-aortic counter pulsation device inserted
inserted percutaneously into the descending aorta via the femoral artery
the catheter of a intra-aortic balloon or intra-aortic counter pulsation device is attached to what and what does it do
attached to IABP which pumps helium into the balloon
the tip of the balloon of intra-aortic balloon or intra-aortic counter pulsation device have what feature
tip of balloon has a radiopaque marker which is seen on a CXR for accurate positioning of the balloon
what does the balloon of the intra-aortic balloon or intra-aortic counter pulsation device do in diastole
balloon inflates when the heart relaxes - diastole - and it pushes the blood towards the coronary sinus and increases coronary arteries perfusion
this increases myocardial oxygen supply
what happens to the intra-aortic balloon or intra-aortic counter pulsation device in systole
when the heart contracts - systole - the balloon deflates (this deflates the balloon) and the left ventricle doesnt have to push against the resistance of the aortic valve as much and increases CO as it acts as a vacuum when it deflates and the valve opens and it sucks out all the blood which reduces the afterload
the amount of pressure the ventricle must generate to open the aortic valve therefore increasing systemic blood flow and therefore increases CO
what type of device is a IABP and what does it help to do
type of therapeutic device
it helps to pump more blood if your heart is unable
how long does the IABP stay in and what does it do
stays in 2-3 days and helps support patient and pump blood of heart
what are 7 indications for a IABP
LV failure
unstable angina
septic shock
complications to acute myocardial infarction
bridge to heart TX
valvular disease
post cardiac surgery
what device is an intra-aortic balloon
counterpulsation device
where is the intra-aortic balloon placed in and where does it end up
placed in the femoral artery and ends up in the descending aorta
how long is the intra-aortic balloon
around 8inches long
what is the intra-aortic balloon shuttled with - what gas and what are the 2 reasons
helium
helium is light, inert and shuttles rapidly
as its helium, if the balloon ruptures wont get embolism as it can dissipate quickly and can diffuse rapidly
what happens if the intra-aortic balloon is positioned too high into the arch
it can interfere with your head and neck blood supply but if its too low, can interfere with renal and mesenteric arteries
what is the correct position of the IABP tip
what is the lowest point
tip should lie at the level of the carina
lowest point is between the carina and left main bronchus
if the IABP is placed too low what can it do
can affect the renal artery and mesenteric artery supply
IABP patients require how many CXRs
require CXR daily
why are IABP patients imaged in supine position
imaged in supine position because the cannula cannot be kinked
why shouldnt you sit the patient up more than 30 degrees for a patient with IABP
as it will kink the cannula in the groin
when the balloon is inflated on a CXR for IABP, what can it be mistaken for
pneumomediastinum
what are 5 reasons for a nasogastric tube
unable to consume adequate nutrition
impaired swallowing - danger of aspirating
facial or esophageal abnormalities or post surgery
eating disorders
primary disease management
what are the 5 functions of a NG tube
administer feeds (unconscious ICU pts)
medications administration (eg liquid charcoal used for drug overdose)
facilitate free drainage and aspirations of the stomach contents
facilitate decompression of the stomach
stent the esophagus (eg post perforation of esophagus)
what happens when trauma pts are anxious in terms of the stomach - what do these patients need
may swallow a lot of air into stomach so needs decompression
where do you want the tip of the NG tube to be
Want tip to be at least 10cm past the gastroesophageal junction because its got side holes coming down near the tip and don’t want side holes in the esophagus
what happens if you put the NG tube too far down
could block outlet of stomach either
where is the diaphragm in terms of what abdominal junction
Gastroesophageal junction is where diaphragm is here
what is the path of the NG tube
tube follows a straight course down the midline of the chest to the point below the diaphragm
tube doesn’t not follow the path of a bronchus
tube is not coiled anywhere in the chest
tip of tube is below the diaphragm
what can aging do to the oesophagus
make it more tortuous
where are the 7 locations where the NG tube can be mispositioned
NGT coiled in nasopharynx or oropharynx
NGT placed in mid/distal oesophagus not stomach or has doubled back up the oesophagus
NGT entered stomach and doubled back up the osephagus
NGT placed to level of the cardia not in fundus
NGT placed at pyloric sphincter obstructing outflow
NGT in duodenum
NGT placed in stomach but tube kinked
why do you always need to include the neck on the CXR when evaluating NGT
to show an coils in the nasopharynx or oropharynx
what is a hiatal hernia
stomach is raised and esophagus is shortened so stomach sits behind heart
what is situs invertus
all body organs are mirrored - other way round to normal
what are the 7 indications for nasojejunal tube placements
pts at high risk of aspiration
delayed gastric emptying - ICU pt can have reduced gastric absorption/motility
acute pancreatitis
paralytic ileus causing reflux/vomiting
obstructive lesions high in GI tract
partial gastric outlet obstruction
gastric or duodenal fistula
what are percutaneous endoscopic gastrostomy tube and when is it used
PEG is used when a NGT is contraindicated and there is a requirement for long term enteral nutrition
what are 8 indications for taneous endoscopic gastrostomy tubes
head injury
cancer - head/nek/oesophagus
burns
facial surgery
dementia
poly trauma
ICU patients
strokes - dysphagia
how and where is the percutaneous jejunostomy tube
percutaneously placed directly into the proximal jejunum
what are 3 main indications for placement of a percutaneous jejunostomy tube
major surgery to the upper digestive tract
pathology to the upper digestive tract that would contraindicate other forms of feeding tubes
to administer nutrition
