Central Lines Flashcards
when is the central line considered correctly placed?
distal tip of catheter is at the junction of the superior vena cava and right atrium
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
what is the most common central line access site used when peripheral attempts fail?
external jugular (EJ)
3 long term indications for central line?
chemotherapy
long term abx
total parenteral nutrition
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
which is more likely to be infected an a line or central line? why?
central line because blood flow/pressure is lower
how is accidental arterial puncture ruled out?
color of blood
transducing the blood pressure
how to avoid artery puncture
insert needle lateral to the carotid pulse when performing a central line
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
what causes transient arrhythmias during insertion of central line
seldinger wire irritating the myocardium
ectopy is good
air embolism
large bubble in the vein that travels to the heart and causes an obstruction in the pulmonary artery
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
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
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
why does trendelenburg decrease likelihood of air embolism?
increases venous pressure engorges the vein and makes air entrainment less likely
if the blood pressure in the vein is low does that make air entrainment more or less likely?
more likely
when will the effects of surgical site being above heart for air embolism be more pronounced?
hypovolemic patient
what is the best (most sensitive method for detecting venous air embolism?
TEE
how does the precordial doppler detect an air embolism
air embolism is indicated by sporadic roaring sounds as opposed to regular swishing sounds
when would you use the precordial doppler over the TEE
when it is a field avoidance case and TEE is impractical
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
why do you want to be in left lateral trendelenburg?
puts the air in the bottom of the RV
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
EJ advantage
most superficial and easy to cannulate
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
