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LANCE > Central Lines > Flashcards

Central Lines Flashcards

1
Q

when is the central line considered correctly placed?

A

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

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2
Q

8 indications for central lines

A

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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3
Q

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

A

external jugular (EJ)

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4
Q

3 long term indications for central line?

A

chemotherapy
long term abx
total parenteral nutrition

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5
Q

8 complications of a central line

A 
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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6
Q

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

A

central line because blood flow/pressure is lower

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7
Q

how is accidental arterial puncture ruled out?

A

color of blood

transducing the blood pressure

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8
Q

how to avoid artery puncture

A

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

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9
Q

what are the characteristics of a pneumothorax on an xray?

A

translucency and absence of valcular markings

trachea and mediatinum can be shifted to contralateral side

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10
Q

what causes transient arrhythmias during insertion of central line

A

seldinger wire irritating the myocardium

ectopy is good

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11
Q

air embolism

A

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

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12
Q

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

A

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

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13
Q

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

A

during central line placement

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

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14
Q

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

A

keep catheter occluded as much as possible

place the patient in trendelenburg during central line placement

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15
Q

why does trendelenburg decrease likelihood of air embolism?

A

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

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16
Q

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

A

more likely

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17
Q

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

A

hypovolemic patient

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18
Q

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

A

TEE

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19
Q

how does the precordial doppler detect an air embolism

A

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

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20
Q

when would you use the precordial doppler over the TEE

A

when it is a field avoidance case and TEE is impractical

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21
Q

6 steps for treatment of air embolism

A

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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22
Q

why do you want to be in left lateral trendelenburg?

A

puts the air in the bottom of the RV

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23
Q

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

A 
EASY
right IJ
left subclavian
left IJ
right subclavian
right and left EJ
HARD
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24
Q

EJ advantage

A

most superficial and easy to cannulate

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25
Q

EJ disadvantages 2

A

tortuous path to SVC

significant risk of infxn (hair and secretions)

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26
Q

clinical use for the EJ

A

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

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27
Q

IJ advantages 2

A

good visualization with ultrasound standard of care

RIGHT IJ provides easiest path to SVC

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28
Q

IJ disadvantages 4

A

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

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29
Q

subclavian advantages 2

A

lowest infxn rate

most comfortable for pt

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30
Q

right vs left subclavian

A

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

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31
Q

4 disadvantages to the subclavian approach

A

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

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32
Q

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

A

more likely

hold ventilation during needle insertion

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33
Q

pinch off phenomenon/syndrome w/ subclav approach

A

catheter compressed between clavicle and first rib

obstruction/tearing and embolization of catheter

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34
Q

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

A

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

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35
Q

why is the axillary vein considered safer than the subclavian?

A

ability to visualize the vein with ultrasound

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36
Q

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

A

axillary vein

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37
Q

femoral vein advantage

A

easier sites in emergency (only used in emergency)

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38
Q

femoral vein disadvantage 3

A

risk of arterial puncture, infxn, and venous thromboembolism highest

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39
Q

how soon should a femoral line be replaced?

A

24 hours

40
Q

4 risks unique to the femoral approach

A

femoral artery puncture
femoral nerve injury
bladder perforation
peritoneal perforation

41
Q

what is the pneumonic for femoral central line placement?

A

NAVEL

42
Q

venous return

A

refers to the amount of venous blood returning to heart

associated with CVP

43
Q

normal CVP indicates what about venous return

A

adequate venous return

44
Q

low CVP indicates what about venous return

A

decreased venous return

45
Q

4 factors that affect venous return

A

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

46
Q

euvolemia

A

normal venous return

47
Q

hypovolemia

A

low venous return

48
Q

high intrathoracic pressure

A

decreased venous return (pospressure)

49
Q

low intrathoracic pressure

A

increased venous return (spon vent)

50
Q

does vasodilation increase or decrease venous return?

A

decrease

51
Q

which has increased venous return? trendelenburg or reverse trendelenburg?

A

trendelenburg

52
Q

Normal CVP

A

5-12mmHg

53
Q

What are the two purposes of monitoring CVP?

A

assess pt volume status/venous return

assess right heart function

54
Q

3 causes of low CVP

A

hypovolemia
reverse trendelenburg
vasodilation

55
Q

treatment for low CVP

A

volume resuscitation

56
Q

6 causes of high CVP

A 
fluid overload
HF
pulmonary HTN
trendelenburg
high intrathoracic pressure
tricuspid/pulmonary stenosis or regurg
57
Q

treatment for high CVP

A

restricting fluids

administering inotrope or diuretic

58
Q

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

A

decrease venous return

increase CVP

59
Q

a wave

A

end of ventricular diastole

atrial contraction

60
Q

c wave

A

early ventricular systole

ventricular contraction

61
Q

x descent

A

mid ventricular systole

atrial relaxation during ven sys

62
Q

v wave

A

late systole

blood filling in the right atrium (during relaxation)

63
Q

y descent

A

early diastole

opening of tricuspid valve (prior to atrial contraction)

64
Q

cannon wave

A

abnormally tall wave on CVP

65
Q

cause for cannon A wave

A

tricuspid stenosis
complete heart block
junctional rhythm

66
Q

cannon v wave cause

A

tricuspid regurge

x descent is abolished

67
Q

what are the 3 systolic waves?

A

C, X, V

68
Q

what are the 2 diastole waves

A

Y, A

69
Q

gauge of brown lumen triple lumen central line 7F

A

16ga

70
Q

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

A

18ga

71
Q

distal brown lumen function

triple lumen 7F

A

used for CVP

non compliant transducer tubing attached

72
Q

two proximal lumes white, blue

triple lumen 7F

A

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

73
Q

double lumen 7F

brown and white ports gauges and function

A

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

74
Q

two types of lines that have introducer port

A

8.5F percutaneous sheath introducer PSI (Cordis)

double lumen 9F MAC catheter

75
Q

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

A

float insert pacing wires

pulmonary artery swan ganz catheter

76
Q

advantage of introducer port lines

A

larger (8.5F or 9F)

77
Q

disadvantage of introducer port lines

A

typically have less ports

we have ability to add more if needed

78
Q

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

A

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

79
Q

what can the pulm artery swan ganz add port wise?

A

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

80
Q

what can the companion catheter add port wise?

A

single or double lumen catheter allows infusions and/or CVP

81
Q

what can the SLIC catheter add port wise?

A

one port that allows CVP monitoring

82
Q

how large can dialysis catheters be?

A

14F

83
Q

dialysis central line

A

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

84
Q

2 central lines for long term therapy

A

Peripherally inserted central catheter line (PICC)

tunneled catheter

85
Q

2 tunneled catheters

A

mediport

broviac

86
Q

PICC lines

A

long catheter from antecubital vein

single, double or triple lumen

87
Q

do PICC lines have slow or fast drip rates?

A

SLOW

88
Q

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

A

no, place another IV

89
Q

the difference between mediport and broviac catheters

A 
mediport= sewn under skin, requires stick for access
broviac= port exit body, higher infxn rate
90
Q

mediport placement

A

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

91
Q

what type of needle is used for access to a mediport

A

huber needle

92
Q

can you use a mediport for general anesthesia?

A

yes

93
Q

broviac access

A

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

94
Q

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

A

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

95
Q

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

A

before and after drug administration

LANCE (17 decks)

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