Central Lines Flashcards by Taylor Brundage

when is the central line considered correctly placed?

distal tip of catheter is at the junction of the superior vena cava and right atrium

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8 indications for central lines

1-larger IV access for fluids or blood rapidly
2-IV access when peripheral attempts fail
3- monitor central venous pressure
4- insert a pulmonary artery catheter (swan ganz)
5- administer medications contraindicated to administer peripherally
6- temporary emergency hemodialysis
7- place temporary transvenous pacing wires
8- aspirate air emolism from the heart

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what is the most common central line access site used when peripheral attempts fail?

external jugular (EJ)

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3 long term indications for central line?

chemotherapy
long term abx
total parenteral nutrition

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8 complications of a central line

1-infxn
2- venous stenosis
3- accidental arterial puncture
4- thrombosis (picture of babies black foot)
5-pneummothorax (lances first attempt)
6- transient arrhythmias during insertion
7- nerve injury
8- air embolism

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which is more likely to be infected an a line or central line? why?

central line because blood flow/pressure is lower

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how is accidental arterial puncture ruled out?

color of blood

transducing the blood pressure

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how to avoid artery puncture

insert needle lateral to the carotid pulse when performing a central line

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what are the characteristics of a pneumothorax on an xray?

translucency and absence of valcular markings

trachea and mediatinum can be shifted to contralateral side

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what causes transient arrhythmias during insertion of central line

seldinger wire irritating the myocardium

ectopy is good

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air embolism

large bubble in the vein that travels to the heart and causes an obstruction in the pulmonary artery

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what are the signs and symptoms of an air embolism? (4)

1- sudden decrease in et CO2
2- sudden increase in et Nitrogen
3- hypotension/tachycardia
4- cyanosis

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what are the two risk factors for development of an air embolism?

during central line placement

develop air embolism if the surgical site is above the level of the heart

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what should we do during placement to decrease likelihood of air emolism

keep catheter occluded as much as possible

place the patient in trendelenburg during central line placement

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why does trendelenburg decrease likelihood of air embolism?

increases venous pressure engorges the vein and makes air entrainment less likely

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if the blood pressure in the vein is low does that make air entrainment more or less likely?

more likely

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when will the effects of surgical site being above heart for air embolism be more pronounced?

hypovolemic patient

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what is the best (most sensitive method for detecting venous air embolism?

TEE

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how does the precordial doppler detect an air embolism

air embolism is indicated by sporadic roaring sounds as opposed to regular swishing sounds

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when would you use the precordial doppler over the TEE

when it is a field avoidance case and TEE is impractical

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6 steps for treatment of air embolism

1-flood surgical field with saline
2- deliver 100% O2
3- place patient in left lateral trendelenburg and aspirate air through central line port
4- give volume to increase CVP
5- start a central line and aspirate air out
6- support patients BP

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why do you want to be in left lateral trendelenburg?

puts the air in the bottom of the RV

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list in order from easiest to hardest (path) the veins to use for central lines

EASY
right IJ
left subclavian
left IJ
right subclavian
right and left EJ
HARD

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EJ advantage

most superficial and easy to cannulate

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EJ disadvantages 2

tortuous path to SVC | significant risk of infxn (hair and secretions)

clinical use for the EJ

access with regular IV catheter when you need a 2nd for surg and cannot access another site

IJ advantages 2

good visualization with ultrasound **standard of care** | RIGHT IJ provides easiest path to SVC

IJ disadvantages 4

close to carotid artery significant risk of infxn (facial hair, secretions) risk of pneumothorax uncomfortable to the pt

subclavian advantages 2

lowest infxn rate | most comfortable for pt

right vs left subclavian

left subclavian makes a more gradual curve into the right atrium and is easer than right

4 disadvantages to the subclavian approach

1- ultrasounds does not provide benefit 2- highest risk of pneumothorax 3-bleeding is difficult to control (noncompressible) 4- pinch off phenonmenon/syndrome

is a pneumothorax more or less likely with a mechanically ventilating pt subclavian approach?

more likely | hold ventilation during needle insertion

pinch off phenomenon/syndrome w/ subclav approach

catheter compressed between clavicle and first rib | obstruction/tearing and embolization of catheter

how can pinch off phen/syn be recognized? w/ subclav approach

difficult flushing or aspiration with arm in certain postions confirmed with xray

why is the axillary vein considered safer than the subclavian?

ability to visualize the vein with ultrasound

which has a lower chance of accidental arterial puncture and pneumothorax? axillary or subclavian?

axillary vein

femoral vein advantage

easier sites in emergency (only used in emergency)

femoral vein disadvantage 3

risk of arterial puncture, infxn, and venous thromboembolism highest

how soon should a femoral line be replaced?

24 hours

4 risks unique to the femoral approach

femoral artery puncture femoral nerve injury bladder perforation peritoneal perforation

what is the pneumonic for femoral central line placement?

NAVEL

venous return

refers to the amount of venous blood returning to heart | associated with CVP

normal CVP indicates what about venous return

adequate venous return

low CVP indicates what about venous return

decreased venous return

4 factors that affect venous return

1-volume status 2- intrathoracic pressure 3-level of vasodilation 4- patient positioning

euvolemia

normal venous return

hypovolemia

low venous return

high intrathoracic pressure

decreased venous return (pospressure)

low intrathoracic pressure

increased venous return (spon vent)

does vasodilation increase or decrease venous return?

decrease

which has increased venous return? trendelenburg or reverse trendelenburg?

trendelenburg

Normal CVP

5-12mmHg

What are the two purposes of monitoring CVP?

assess pt volume status/venous return | assess right heart function

3 causes of low CVP

hypovolemia reverse trendelenburg vasodilation

treatment for low CVP

volume resuscitation

6 causes of high CVP

``` fluid overload HF pulmonary HTN trendelenburg high intrathoracic pressure tricuspid/pulmonary stenosis or regurg ```

treatment for high CVP

restricting fluids | administering inotrope or diuretic

does intrathoracic pressure increase or decrease venous return? what about CVP?

decrease venous return | increase CVP

a wave

end of ventricular diastole | atrial contraction

c wave

early ventricular systole | ventricular contraction

x descent

mid ventricular systole | atrial relaxation during ven sys

v wave

late systole | blood filling in the right atrium (during relaxation)

y descent

early diastole | opening of tricuspid valve (prior to atrial contraction)

cannon wave

abnormally tall wave on CVP

cause for cannon A wave

tricuspid stenosis complete heart block junctional rhythm

cannon v wave cause

tricuspid regurge | x descent is abolished

what are the 3 systolic waves?

C, X, V

what are the 2 diastole waves

Y, A

gauge of brown lumen triple lumen central line 7F

16ga

gauge of white and blue lumen triple lumen central line 7F

18ga

distal brown lumen function | triple lumen 7F

used for CVP | non compliant transducer tubing attached

two proximal lumes white, blue | triple lumen 7F

hooked to IV tubing used for fluids, bolusus or infusion lines

double lumen 7F | brown and white ports gauges and function

both 16ga brown= distal (CVP) White= fluids/infusions

two types of lines that have introducer port

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

what are the two reasons that an introducer port is required?

float insert pacing wires | pulmonary artery swan ganz catheter

advantage of introducer port lines

larger (8.5F or 9F)

disadvantage of introducer port lines

typically have less ports | we have ability to add more if needed

3 options for adding more ports to a cordis or 9F MAC catheter

1-pulmonary artery swan ganz catheter 2- companion catheter 3- single lumen infusion catheter (SLIC)

what can the pulm artery swan ganz add port wise?

3 extra ports 1= CVP 1= infusion 1= pulm art pressure

what can the companion catheter add port wise?

single or double lumen catheter allows infusions and/or CVP

what can the SLIC catheter add port wise?

one port that allows CVP monitoring

how large can dialysis catheters be?

14F

dialysis central line

used for short term acute problems one lumen blood draws out and other reinfuses the blood

2 central lines for long term therapy

Peripherally inserted central catheter line (PICC) | tunneled catheter

2 tunneled catheters

mediport | broviac

PICC lines

long catheter from antecubital vein | single, double or triple lumen

do PICC lines have slow or fast drip rates?

SLOW

do you use a PICC line if the patient will require significant fluid replacement?

no, place another IV

the difference between mediport and broviac catheters

``` mediport= sewn under skin, requires stick for access broviac= port exit body, higher infxn rate ```

mediport placement

subclavian central line started by surgeon surgeon hooks up line to a port port is surgically tunneled under skin and skin is closed

what type of needle is used for access to a mediport

huber needle

can you use a mediport for general anesthesia?

yes

broviac access

sterile dressing should cover the exit site at all times, infxn rate is higher

why must you aspirate at least 10mL of blood through the mediport and broviac catheters before dosing any fluid or drugs?

heparin may be required to prevent clot formation thus you dont want to give the patient a large unintended dose of heparin

when should the mediport/broviac catheters be flushed with LR or N/S?

before and after drug administration