Chapter 22 The Role of Ultrasound in Central Access Device Placement Flashcards
inadvertent release of air or gas into the venous system
air embolism
preexisting veins that enlarge to take flow from neighboring but occluded vessels
collateral veins
an abnormal connection or passageway between two organs or vessels; may be caused by trauma or intentionally for therapeutic purposes
fistula
The brightness of an ultrasound image, which can be manipulated on most devices
gain
a hydrophilic guidewire
glidewire
A Nitinol or stainless steel wire used to support sheath or catheter exchanges and to predict vessel patency; measured in diameter and length
guidewire
leaking of intravenous fluid from a catheter into the tissue surrounding the vein
infiltration
Innermost layer of a vein or an artery; composed of one layer of endothelial cells in contact with blood flow; also known as tunica intima
intima
small needles are wires used to make the initial access into a target
microintroducer
A sheath that is perforated along the long axis, allowing the device to be split for removal from a catheter
peel-away sheath
A type of vascular access device that is typically inserted into a vein of the upper extremity and threaded to achieve a tip location in the distal third of the superior vena cava
peripherally inserted central catheter (PICC)
Collection of air in the pleural space (between the lung and the chest wall)
pneumothorax
A thin-walled, hollow plastic tube through which wires and catheters can be advanced; measured in Fr size according to the size of the catheter it can accomodate
sheath
Narrowing of a vein or an artery because of disease or trauma
stenosis
Different reasons for venous access
intravenous antibiotic therapy
central venous pressure monitoring and sampling
hemodialysis
chemotherapy
total parenteral nutrition
catheters that allow clinicians to infuce medications and blood components, obtain blood samples, and deliver other exchange therapies
Vascular access devices
catheters placed such that the terminal tip of the catheter resides in a central vein, most often the superior vena cava
central VAD
single- or dual- lumen devices with the tip remaining in the peripheral vein and do not cross into the axillary vein
midline catheteres
Most common places for central VAD placement
peripheral
basilic
cephalic
brachial
subclavian
internal jugular
external jugular
The central VAD catheter typically resides ______
in the distal third of the SVC or slightly deeper at the atriocaval junction
flow rate of atriocaval junction
2000 mL/min
Three categories of VADS
nontunneled devices
tunneled devices
implanted ports
VADs that are place percuteaneously into a central or peripheral vein, with the device’s tip residing at the atriocaval junction or in the distal third of the SVC
nontunneled central VADs
critical care catheters
temporary dialysis and apheresis catheters
small bore polyurethane or silicone catheters
PICCS
nontunneled central VADs
secured at the puncture site with sutures, subcuteaneous securement devices, or adhesive securement devices
nontunneled central VADs
placed via a central vein with their tip residing at the atriocaval junction or in the distal third of the SVC
Tunneled VADs
tunneled under the skin to an exit site, typically located several centimeters from the puncture site into the vein to provide stability for the device and reduces the risk of device-related infection
tunneled VADs
infusions
long term dialysis or apheresis
tunneled VADs
VADs with a catheter segment attached to a plastic or titanium reservoir. The entire system is placed under the skin.
implanted ports
patients who require intermittent therapy such as weekly or monthly
implanted ports
dominant superficial vein of the upper extremity
basilic vein
Basilic vein blood flow velocity
80 mL/min
vein of first choice for placement of PICCs
basilic vein
drains directly into axillary vein, which becomes SVC as it enters chest
basilic vein
smallest major vein in upper extremity
cephalic vein
blood flow velocity of cephalic vein
30 mL/min
least preferred choice for VAD placement in upper extremity
cephalic vein
Most common sites for central venous access
IJVs
SCVs
The ____ IJV is more preferred for VAD placement because it has a straighter course to the heart
right
drain blood from the face and the neck
EJV and anterior jugular vein
joins IJV at confluence of SCVs and brachiocephalic veins
EJV
____ are commonly used to attain central venous access, located in the chest, usually directly under the clavicle
SCVs
terminate in brachiocephalic veins join to form:
superior vena cava
The IJV is located ____ and _____ to CCA
anterior
lateral
located in groin medial to CFA
Common femoral vein
drain blood from lower extremities into external iliac veins
common femoral veins
most often used for central venous access in emergent situations
common femoral veins
VAD sonographic appearance
parallel hyperechoic linear structure
occurs each time a vein is accessed
vein damage
3 layers of vein
intima
media
adventitia
innermost lining of vein, single layer of endothelial cells
tunica intima
leaking of fluid from a catheter into tissue around vein
infiltration
may occur if catheter passes through wall of vein or slips out of vein
infiltration
initial needle placed through both walls of vein into neighboring artery
arterial venous fistula
occurs when access needle is directed to a neighboring structure
nontarget puncture
one of the most serious and potentially life threatening complications of central venous catheterization
pneumothorax
occurs when air enters the venous system via the needle, sheath, or device; can result in respiratory compromise or death
air embolism
typically occur when guidewires are advanced into heart, triggering hearts conduction system
cardiac arrhythmias
Central venous access may be used in patients requiring which of the following?
a. intravenous antibiotic therapy
b. chemotherapy
c. total parentural nutrition
d. all of the above
d
Which of the following is NOT one of the most commonly used peripheral access points for VAD placement?
a. basilic vein
b. cephalic vein
c. popliteal vein
d. internal jugular vein
c
Why is the aortocaval junction a desirable location for placement of the VAD catheter tip?
flow rates are around 2000 mL/min
What is a type of VAD that is placed percuteaneously into a central or peripheral vein with its end secured at the puncture site?
nontunneled central VAD
Which of the following is a type of VAD in which the catheter exits the skin away from the puncture site?
a. tunneled central VAD
b. nontunneled central VAD
c. implanted port
d. port-a-cath
a
Which of the following is NOT a benefit of a tunneled central VAD?
a. reduction of device-related infection
b. more stable device
c. hidden exit site for cosmetic reasons
d. less comfortable for the patient
d
Implanted ports are typically used in patients who require therapy at what rate?
weekly
Which of the following veins is typically the first choice for placement of peripherally inserted central catheters?
basilic vein
For which of the following patients would it be more common to use the saphenous vein for central vascular access placement?
a. a 75 year old woman
b. a 2 day old infant
c. a 35 year old male
d. a 62 year old male
b
Which of the following describes the preferred use of peripheral cannulas?
a. long term ( >1 week), continuous therapy
b. long term, intermittent therapy
c. therapy lasting several months
d. short term therapy ( <1 week)
d
Which jugular vein is preferred for central VAD placement?
right internal jugular vein
Where is the internal jugular vein typically located in relation to the common carotid artery?
anterolateral
Because of their location around the clavicle, which of the following vessels is more difficult to visualize with ultrasound?
a. axillary vein
b. subclavian vein
c. internal jugular vein
d. basilic vein
b
Which of the following is a reason to avoid the use of the common femoral vein in VAD placement?
a. difficult to visualize on ultrasound
b. preservation for use for lower extremity bypass grafting
c. low flow rates
d. higher rate of mechanical and infectious complications
d
Which of the following is NOT included in the initial assessment for potential access sites for VAD placement?
a. patency of the vessel
b. location of vessel in relation to other structures
c. blood flow velocity
d. ability to access the target vessel
c
How is confirmation of tip placement of a vascular access device typically made?
chest x-ray
A patient presents to the vascular lab after VAD placement to evaluate the basilic vein in which the device is placed. Upon ultrasound evaluation, the basilic vein is noted to have an irregular intimal surface with low-level echoes within the vein lumen. What do these findings suggest?
vein damage with thrombosis
Which of the following is one of the most serious and potentially life-threatening complications of central venous catheterization?
a. pneumothorax
b. arteriovenous fistula
c. thrombosis
d. vein wall damage
a
Which medication would be associated with an increased risk of bleeding during vascular access device placement?
a. clopidogrel
b. warfarin
c. heparin
d. all of the above
d
Which complication of VAD placement is often transient and result in few, if any, symptoms?
a. vein wall damage
b. cardiac arrhythmias
c. arteriovenous fistula
d. pneumothorax
b
Ultrasound is being incorporated increasingly to attain access and place vascular access devices in patients with ______.
difficult access
More centrally located target veins include the ______ and internal _____ veins.
subclavian veins
jugular
The catheter tip of a vascular access device typically resides in the distal third of the ____ at the atriocaval junction
SVC
A vascular access device designed to remain in place long term would be a(n) _____
nontunneled central vascular access device
Vascular access devices with a catheter segment attached to a plastic or titanium reservoir are _____
implanted ports
Because of the location of the brachial veins next to the brachial artery, there is a higher risk of _______ if the brachial veins are used for peripheral VAD placement
inadvertent arterial puncture
When accessing the central veins for central VAD placement, the ____ internal jugular vein is preferred because of a straighter course to the heart
right
Ultrasound allows for _____ assessment of the internal jugular vein before VAD placement as well as dynamic guidance during vein puncture/
anatomic
Using ultrasound guidance during vein puncture can reduce failure of catheter placement as well as complication rates related to ______
insertion
When accessing the internal jugular vein, it is important to identify the ______ before attempting cannulation to avoid serious injury
common carotid artery
Neither the subclavian nor other upper extremity veins should be used for cannulation in patients with _____ to preserve these vessels for hemodialysis in the future.
chronic renal insufficiency or chronic kidney disease
The ______ veins are typically only used for venous access in emergent situations and in patients in whom other potential access veins are occluded.
common femoral
Patency of a vessel for potential access is first tested by ______, similar to that used in the assessment of a patient for deep venous thrombosis.
compressability
On ultrasound, the VAD appears in the lumen of the vein and produces a(n) ______ structure on the image.
parallel hyperechoic linear
The presence of ______ veins upon physical examination should alert the clinician to potential difficulties in successful placement of VADs.
collateral
Thrombosis and arteriovenous fistula formation are examples of complications due to _____.
vein damage
To minimize the impact of ______ puncture, a small access needle should be used.
nontarget
Difficult or traumatic VAD insertion, hematologic disorders, and concurrent treatment with certain medications all increase the risk of ______ during VAD placement
bleeding
Using valved sheaths, performing exchange maneuvers efficiently, and assuring that catheter lumens are flushed, secured, and locked will decrease the risk of _____.
air embolism
When advancing guidewires into the heart during VAD placement, transient, asymptomatic, ______ often occur.
cardiac arrhythmias
