Central venous pressure monitoring

Question 1

Subclavian approach

Answer 1

The skin puncture is made just lateral to, and one fingerbreadth below, the costoclavicular ligament, which can be identified by a notch two thirds of the length
down the clavicle. The needle is directed along the posterior border of the clavicle in the direction of the sternal notch until venous blood is aspirated.

Question 2

3 approaches to the internal jugular vein

Answer 2

1) Low anterior
2) High anterior
3) Posterior

Question 3

This type of IJ approach:
Locate the point at which the sternal and clavicular heads of the sternocleidomastoid muscle join. Introduce the needle at this point and direct it at a 30-degree angle to the skin. Advance the needle toward the ipsilateral nipple until venous blood is aspirated.

Answer 3

Low anterior

Question 4

This type of IJ approach:
Palpate the carotid artery at the level of the cricothyroid membrane. Introduce the needle just lateral to the carotid pulsation and advance it toward the ipsilateral nipple at a 30-degree angle until venous blood is aspirated. This approach frequently requires penetration of the sternocleidomastoid muscle by the introducer needle.

Answer 4

High anterior

Question 5

This type of IJ approach:
Locate the junction of the posterior border of the sternocleidomastoid muscle and the external jugular vein. Introduce the needle just posterior to this point and advance it along the deep surface of the muscle toward the ipsilateral corner of the sternal notch until venous blood is aspirated.

Answer 5

Posterior

Question 6

The needle is advanced in a direction paralleling the vessel and is introduced into the vein approximately two finger widths below the inferior border of the mandible.

Answer 6

External jugular vein

Question 7

This venous cannulation may be undertaken when subclavian or internal jugular catheterization is
unsuccessful. Not a preferred approach because of the high risk of infection

Answer 7

Femoral

Question 8

Although a catheter can be inserted through a large-bore needle, the most common technique involves passing it over a guidewire, commonly referred to as the?

Answer 8

Seldinger technique

Question 9

In attempting a central venous puncture, dark blood returns. Does this satisfy you that you are indeed within a vein?

Answer 9

The best way to determine whether you are indeed in a vein is to thread a short, small-gauge catheter (e.g., 18- or 20-G) over the wire, remove the wire, and transduce the small catheter.

Question 10

At what point on the body should central venous pressure be measured?

Answer 10

The ideal point at which to measure CVP is at the level of the tricuspid valve.

Question 11

An external landmark for the tricuspid is?

Answer 11

Point 2 inches behind the sternum, roughly the anterior axillary line, at the fourth intercostal space.

Question 12

Where should the distal orifice of the catheter be positioned?

Answer 12

The tip of the catheter can be positioned within either the atrium or the vena cava near the caval-atrial junction.

Question 13

Placement of the catheter for aspiration of air emboli during neurosurgical cases requires positioning of the catheter (preferably multiport) tip in the?

Answer 13

Right atrium near the superior vena cava–atrial junction

Question 14

How can you judge the correct positioning of the distal orifice of the catheter?

Answer 14

External landmark - immediately to the right of the third costal cartilage

Question 15

Is the most accurate method for positioning the catheter tip but is time consuming and cumbersome

Answer 15

Advancing the catheter under fluoroscopy

Question 16

Study

Answer 16

With a specialized central venous catheter, the tip can be used as an electrocardiogram (ECG) electrode. After insertion the catheter is filled with electrolyte solution (normal saline or 8.4% NaHCO3), and the V lead of the ECG is attached to a proximal connection. The catheter is advanced toward the right atrium. The P-wave axis and voltage on the V lead tracing indicates the catheter tip position. As the catheter tip passes the area of the sinoatrial node, the P wave becomes equal in height to the R wave of the ECG. The catheter tip passing the mid-atrial position is demonstrated by a decreasing or
biphasic P wave. Low atrial positioning is indicated by an inverted P wave or absence of the P wave.

Question 17

The different waves of CVP. This wave represents

the increase in atrial pressure that occurs during ATRIAL CONTRACTION.

Answer 17

a

Question 18

This wave is the decrease in atrial pressure as the ATRIUM begins to RELAX.

Answer 18

X

Question 19

This wave is caused by the bulging of the TRICUSPID valve into the atrium during the early phases of RIGHT VENTRICULAR CONTRACTION.

Answer 19

c

Question 20

This wave represents the increase in atrial pressure that occurs while the ATRIUM FILLS against a closed tricuspid valve.

Answer 20

v

Question 21

This wave represents a drop in pressure as the VENTRICLES RELAX, the TRICUSPID VALVE OPENS.

Answer 21

y

Question 22

Abnormal central venous pressure waveform be used to diagnose abnormal cardiac events. Such as this ECG finding is characterized by absence of the normal a wave component.

Answer 22

Atrial fibrillation

Question 23

This condition results in a giant V wave that replaces the normal c, x, and v waves.

Answer 23

Tricuspid regurgitation

Question 24

What size of CVP catheters is ideal for blood transfusion?

Answer 24

Nine French triple-lumen catheters have larger lumens and shorter lengths and are satisfactory for blood administration.

Question 25

Pneumothorax may occur with that type of CVP insertion approaches (3)?

Answer 25

1) Subclavian
2) Low anterior (internal jugular)
3) Junctional

Question 26

Hemothorax is common with that type of CVP insertion approach?

Answer 26

Subclavian

Question 27

The thoracic duct, as it wraps around the left internal jugular vein, can reach as high as 3 or 4 cm above the sternal end of the clavicle. This places the duct in a vulnerable position for puncture or laceration with what approach?

Answer 27

Left internal jugular venipuncture

Question 28

To prevent air embolism what maneuver needs to be done for the patient?

Answer 28

Head down

Question 29

Are any special precautions needed when removing a central venous catheter?

Answer 29

Head down to prevent air aspiration.

Apply pressure until clot formation