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Patient Monitoring/ Instrumentation Kristi > Central Lines > Flashcards

Central Lines Flashcards

1
Q

How is a central line considered “correctly placed”

A

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

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2
Q

what are the 8 indications for central lines

A
  1. larger IV access to be able to administer fluids and/or blood at a more rapid rate
    - useful in trauma, massive hemorrage
  2. IV access when peripheral IV access fails
  3. allows us to monitor central venous pressure
  4. With a central line, we can insert a pulmonary artery catheter (Swan Ganz catheter)
  5. Allows us to administer certain medications that are contraindicated to administer peripherally
    - vasopressors, inotropes
  6. temporary emergency hemodialysis
  7. can use central line to place temporary trans venous pacing wires
  8. can use a central line to aspirate an air embolism from the heart
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3
Q

where is the most common central line access site when a peripheral IV cannot be obtained?

A

external jugular (EJ)

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4
Q

From where does a central line allow us to monitor CVP?

A

superior vena cava to assess pre-load

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5
Q

what does a high CVP usually indicate?

A

right heart failure

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6
Q

at what size can an air embolism become fatal in adults?

A

200-300 mL

3-5 mL/kg

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7
Q

What are 3 indications for long term central lines?

A
  1. Chemotherapy
  2. long term antibiotics (Abx)
  3. total parenteral nutrition (TPN)
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8
Q

the two types of central lines that stay in for a prolonged periods of time

A
  1. PICC line
  2. “tunneled” lines
    - mediport
    - broviac
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9
Q

8 complications of central lines

A
  1. infection
  2. venous stenosis
    - catheter can lead to inflammation, scarring, and possible eventual occlusion
    - can be fatal for dialysis patients
  3. accidental arterial puncture
  4. thrombosis
    - associated with multiple attempts
  5. pneumothorax
  6. transient arrhythmias during insertion
    - caused by seldinger wire irritating the myocardium
  7. nerve injury
  8. air embolism
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10
Q

are central lines or arterial lines less prone to infection

A

arterial lines due to higher pressure blood flow

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11
Q

How do you rule out an arterial line puncture when placing a central line?

A
  1. the color of blood

2. transducing the blood pressure

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12
Q

carotid artery puncture can be avoided by inserting the needle _____ to the carotid pulse when placing a central line

A

lateral

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13
Q

2 identifications of a pneumothorax on a chest x-ray

A
  1. absence of vascular markings and translucency (looks cloudy)
  2. trachea and mediastinum can be shifted to the contralateral side
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14
Q

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

A

air embolism

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15
Q

4 signs and symptoms of an air embolism

A
  1. sudden decrease in end tidal CO2
    - due to decrease in pulmonary blood flow
  2. sudden increase in end tidal nitrogen
  3. hypotension/ tachycardia
  4. cyanosis
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16
Q

will PaCO2 be increased or decreased in air embolism

A

increased

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17
Q

2 risk factors for development of an air embolism

A
  1. during central line placement
    - during placement, the needle and catheter in the vein provides a path for air entrapment
  2. if the surgical site is above the level of the heart
    - open veins above the heart will have a lower blood pressure than veins at or below the level of the heart
    - the lower blood pressure in those veins makes it easier for atmospheric air to enter
    * *risk increases when the patient is hypovolemic
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18
Q

when the blood pressure inside the veins is low, air entrapment becomes (more/less) likely?

A

more

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19
Q

2 things a CAA can do to prevent an air embolism while placing a central line

A
  1. keep the catheter occluded as much as possible until the line is all hooked up
  2. place the patient in trendelenburg position
    - this position increases venous pressure, engorges the vein, and makes air entrapment less likely
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20
Q

what is the best (most sensitive) way to diagnose/detect an air embolism

A

TEE

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21
Q

on a precordial doppler, what is the indication of an air embolism?

A

sporadic roaring sounds

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22
Q

in a “field avoidance” (craniotomy), what is the most appropriate method for confirming a venous air embolism

A

precordial doppler

-placing a TEE probe in this situation is impractical

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23
Q

6 treatments for an air embolism

A
  1. flood the surgical field with saline
    - prevents further entrainment of air
  2. Deliver 100% oxygen
  3. immediately place the patient in left lateral trendelenburg and aspirate the air through a central line port
  4. give volume to increase CVP
  5. start a central line and aspirate the air out
  6. support the patients blood pressure
    - vasopressors, inotrope
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24
Q

why do you place the patient in left lateral position for treatment of air embolism?

A

increases the chances that the air will stay in the apex of the right ventricle
-decreases the chances of the air going into the pulmonary artery

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25
Q

central line access sites with the easiest path to the SVC

A
  1. right IJ
  2. left subclavian
  3. left IJ
  4. right subclavian
  5. right and left EJ
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26
Q

One advantage of the EJ

A
  1. most superficial (very easy to cannulate) out of all the central veins
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27
Q

disadvantage of the EJ

A
  1. tortuous path to the SVC
    - makes it difficult to advance a guidewire or long central line catheters
  2. significant risk of infection due to facial hair and closeness to respiratory secretions
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28
Q

clinical use for the EJ

A
  1. the vein is accessed with a REGULAR IV catheter in patients that may be a difficult stick or need a second IV for surgery
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29
Q

What is the EJ mostly used for

A

Used for regular IV access if the patient is a difficult stick-
-EJ is NOT used a legit “central line” because of the tortuous path to the right atrium

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30
Q

2 advantages of the IJ

A
  1. great visualization with ultrasound
    - low complication rate (57% less) when using US with IJ placement
  2. the RIGHT IJ provides the easiest catheter pathway to the right atrium
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31
Q

what type of catheter is most easily threaded through the right IJ

A

pulmonary artery catheter

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32
Q

4 disadvantages to the IJ

A
  1. close proximity to the carotid artery
  2. carries a significant risk of infection (Like the EJ)
    - facial hair, secretions
  3. risk of pneumothorax
  4. uncomfortable to the patient
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33
Q

2 advantages of the subclavian vein

A
  1. lowest infection rate

2. least restricting and most comfortable to the patient

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34
Q

clinical use of the subclavian vein

A

central lines and pulmonary artery catheters are threaded in to the heart much easier if the LEFT subclavian is used
-LEFT side makes a more gradual curve into the right atrium

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35
Q

4 disadvantages of the subclavian

A
  1. ultrasound guidance does not provide much benefit
  2. carries the highest risk of pneumothorax
  3. bleeding is difficult to control (it is a non compressible vein)
  4. pinch off phenomenon or pinch off syndrome is possible
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36
Q

what vein carries the highest risk of pneumothorax

A

subclavian vien

-higher risk in mechanically ventilated patients

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37
Q

how to avoid pneumothorax in ventilated patients

A

hold ventilation during needle insertion

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38
Q

where the catheter can be compressed between the clavicle and first rib and results in obstruction, tearing, and embolization of the catheter

A

“pinch off phenomenon” or “pinch off syndrome”

-subclavian vein

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39
Q

how do you recognize pinch off phenomenon or syndrome in the subclavian?

A

difficult flushing or aspiration with the arm in certain positions
-confirmed with a chest x-ray

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40
Q

the axillary vein (infraclavicular) is considered a _____ approach than subclavian cannulation. Why?

A
  • safer

- ability to visualize the vein with ultrasound

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41
Q

what are 2 advantages to using the axillary vein vs. the subclavian vein?

A
  1. lower chance of accidental arterial puncture
    - greater distance between artery and veins
  2. lower chance of pneumothorax
    - greater distance from the vein to the rib cage
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42
Q

advantage of femoral vein

A
  1. easier access sites in an emergency
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43
Q

which vein should only be used in emergency

A

femoral vein

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44
Q

3 disadvantages to femoral vein

A
  1. risk of arterial puncture
  2. infection
  3. venous thromboembolism (VTE)
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45
Q

when should a femoral line be replaced?

A

within the next 24 hours

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46
Q

which vein has the highest risk of infection

A

femoral vein

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47
Q

which vein has the highest risk for venous thromboembolism?

A

femoral vein

48
Q

4 risks unique to femoral vein approach

A
  1. femoral artery puncture
  2. femoral nerve injury
  3. bladder perforation
  4. peritoneal perforation
49
Q

acronym for femoral line central placement

A 
NAVEL
(Lateral to medial)
Nerve
Artery
Vein
Empty
Lymphatics
50
Q

clinical term that refers to the amount of venous blood returning to the right atrium

A

venous return

51
Q

venous return is associated with what pressure?

A

CVP

52
Q

when the venous return is decreased, the CVP will be Low/high?

A

low

53
Q

4 factors that affect venous return

A
  1. volume status
  2. intrathoracic pressure
  3. level of vasodilation
  4. patient positioning
54
Q

normal venous return

A

euvolemia

55
Q

reduced venous return

A

hypovolemia

56
Q

3 things that cause high intrathoracic pressure

A
  1. positive pressure ventilation
  2. PEEP
  3. tension pneumothorax
57
Q

high intrathoracic pressure (puts/relieves) external pressure on central veins and (increases/decreases) resistance and causes and (increased/decreased) venous return

A

puts
increases
decreased

58
Q

what causes negative intrathoracic pressure

A

inhalation during spontaneous ventilation

59
Q

negative intrathoracic pressure (puts/relieves) pressure external to the central veins, which (increases/decreases) resistance to blood flow and (increases/decreases) venous return

A

relieves
decreases
increases

60
Q

vasodilation causes blood to pool in the legs and (increases/decreases) venous return

A

decreases

-decreases pre-load

61
Q

trendelenburg gives a (higher/lower) venous return

A

higher

62
Q

reverse trendelenburg gives a (higher/lower) CVP

A

lower

63
Q

represents the blood pressure inside a central vein

A

CVP

64
Q

what is a normal CVP?

A

5-12 mmHG

65
Q

2 benefits to CVP monitoring

A
  1. assess patient’s volume status and venous return
    - low CVP in a supine position indicates hypovolemia and decreased venous return
  2. assess RIGHT heart function
66
Q

right heart failure is indicated by a (high/low) CVP

A

high

67
Q

3 possible causes to a LOW CVP

A
  1. hypovolemia
  2. reverse trendelenburg or sitting beach chair position
  3. vasodilation
    - increases pooling of blood in legs and decreases pre-load
68
Q

hypovolemia causes (high/low) CVP

A

low

69
Q

what is the treatment for LOW CVP?

A

volume resuscitation

70
Q

6 causes for HIGH CVP

A
  1. fluid overload
    - hard unless pt has renal or heart failure
  2. heart failure (cardiac tamponade)
  3. pulmonary hypertension
  4. trendelenburg position
  5. high intrathoracic pressure
  6. tricuspid/ pulmonary regurge
71
Q

2 treatments for HIGH CVP

A
  1. restricting intraoperative fluids

2. administering an inotrope (if pt has heart failure) or a diuretic

72
Q

why does intrathoracic pressure decrease venous return, but increase CVP?

A

venous return from the head/neck also decreases, starts to pool in the head and central veins, which distends these veins and causes an increase in CVP

73
Q

“a” wave on CVP waveform

A

end of diastole

atrial contraction

74
Q

c wave on CVP waveform

A

early systole

ventricular contraction

75
Q

x descent on CVP waveform

A

mid systole

atrial relaxation during ventricular systole

76
Q

v wave on CVP waveform

A

late systole

blood filling in the right atrium (during relaxation)

77
Q

y descent on CVP waveform

A

early diastole

opening of tricuspid valve (just prior to atrial contraction)

78
Q

an abnormally tall wave on a CVP waveform?

on which waves does this occur?

A

cannon wave

-usually occurs with a and v waves

79
Q

3 causes of cannon A waves

A
  1. tricuspid stenosis
    - due to right atrium beating against a partially closed tricuspid valve
  2. complete heart block
    - occurs irregularly, when atria and ventricles happen to contract simultaneously
  3. junctional rhythm
    - atria contracts late or closer to the time the ventricles contract
80
Q

when does a cannon wave occur?

A

when there is an increase in pressure in the right atrium during atrial contraction

81
Q

cause of a cannon V wave

A
  1. tricuspid regurge
82
Q

when does a cannon V wave occur?

A

when there is an increase in right atrial pressure during the atrial relaxation period
-x descent is abolished and v wave is elevated when volume from the ventricle back flows into the right atrium during ventricular systole

83
Q

which waves of CVP are the systole waves?

A

C, X, V

84
Q

which waves of CVP are the diastole waves?

A

Y, A

85
Q

what makes up a triple lumen central line

A

one distal and two proximal lumens

86
Q

what size and color is the distal lumen on the triple lumen central line?

A

16 G

brown

87
Q

what is the distal lumen used for in a triple lumen central line?

A

used for CVP and hooked up to the non-compliant transducer tubing

88
Q

what size and colors are the 2 proximal lumens in the triple lumen central line?

A

18 G

white and blue

89
Q

what lumens in the triple lumen catheter are hooked up to the IV tubing for fluid bolus or infusion lines?

A

white and blue

90
Q

what size is the triple lumen catheter

A

7F

91
Q

what size is the double lumen central line

A

7 F

92
Q

what size and color is the port of the double lumen central line used for CVP?

A

16 G

brown distal

93
Q

what size and color is the port of the double lumen central line used for fluids/infusions/

A

16 G

white proximal

94
Q

what are the two types of central lines with introducer ports

A
  1. 8.5 F percutaneous sheath introducer (PSI)

2. Double Lumen 9F MAC catheter

95
Q

another name for the PSI introducer port

A

cordis

96
Q

what type of central line is required to place pacer wires or a Swan Ganz Catheter

A

introducer port

97
Q

advantage of an introducer port

A

-larger 8.5-9F

98
Q

disadvantage of an introducer port

A

have less ports

99
Q

what additional ports can be added to an introducer port?

A
  1. pulmonary artery Swan Ganz Catheter
    - gives 3 extra ports: CVP, infusions, pulmonary artery pressure monitoring
  2. companion catheter
    - single lumen or double lumen to give infusions or monitor CVP
  3. sinle lumen infusion catheter (SLIC)
    - one port that allows CVP monitoring
100
Q

additional port added to an introducer port that gives 3 extra ports
What are they used for?

A

Swan Ganz Catheter

-CVP, Infusions, pulmonary artery pressure monitoring

101
Q

additional port added to an introducer port that gives a single or double lumen
What are they used for?

A

companion catheter

-give infusions or monitor CVP

102
Q

additional port added to an introducer port that provides a single lumen
what is it used for?

A

single lumen infusion catheter (SLIC)

-allows CVP monitoring

103
Q

how large can a dialysis central line be?

A

14 F

104
Q

a dialysis central line is placed as a (short/long) term solution

A

short

105
Q

what are the functions of the 2 lumens of a dialysis central line?

A

one lumen draws blood away to the dialysis machine

the other lumen re-infuses the “purified” blood

106
Q

a very long catheter that is guided into the superior vena cava through the antecubital vein for long term use

A

PICC line

107
Q

how many lumens can a PICC line have?

A

single, double or triple

108
Q

PICC lines have (fast/slow) drip rates

A

slow

long catheter length=more resistance=slower drip rates

109
Q

tunneled catheter that is sewn under the skin, has a lower infection rate, and requires a needle stick for access

A

mediport

110
Q

tunneled catheter that exits the body, has a higher infection rate, and no needle stick is required

A

broviac

111
Q

what vein is a mediport placed in

A

subclavian

112
Q

tha name of the needle to access the mediport

A

Huber needle

113
Q

mediport and broviac catheters require the use of _____ to prevent clotting formation inside the catheter

A

heparin

114
Q

how many mL of blood should be aspirated from mediport and broviac catheters prior to dosing fluids/drugs

A

10 mL

115
Q

the CAA should flush the mediport and broviac lines with ____ or _____before and after drug administration

A

LR or NS

Patient Monitoring/ Instrumentation Kristi (4 decks)

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