Session 27. Central Lines - Old School Flashcards
central line indications
measure CVP
measure PAP
measure wedge pressure
measure ScvO2
admin lg volume fluid
admin caustic meds
aspirate air emboli
insert pacer leads
hemodialysis
cardiac catheterization
venous access
prolonged IV access
ScvO2
central venous oxygenation
central venous oxygenation
oxygen tension in venous blood after going to the body
what pts might need a central line to establish venous access?
IV drug abusers
major burns
severe dehydration
severe morbid obesity
what type of line can be inserted for prolonged IV access?
PICC
where can PICC lines be placed?
brachial
axilary
basilic
central line relative CI
tumors
clots
tricuspid valve vegetation
(endocarditis)
burns
when are burns CI to placing central line
after 3 days due to higher risk of bacterial colonization and infection
central line absolute CI
abx allergy
hx of severe anatomical distortion of access site
what type of abx are found in central line catheters
tetracycline
rifampin
chlorhexidine
when can you bypass a relative CI for central line?
in an emergency
IJ central line relative CI
cervical trauma w/swelling
cervical instability
subclavian central line relative CI
clavicular or 1st rib sx/trauma
cannulate ispilateral SCV to that of chest wall traum
femoral central line relative CI
intraabdominal hemorrhage
pelvis injury
know/suspect DVT
central line general complications
arterial puncture
hematoma
vessel injury (fistula)
air embolism
catheter embolus
cardiac dysrhythmia
thrombosis
catheter musplacement
lost seldinger wire
catheter knotting
central line infectious complications
bloodstream infection
generalized sepsis
septic arthritis
osteomyelitis
cellulitis at insertion site
central line thrombotic complications
pulmonary embolism
venous thrombosis
neurologic complications
phrenic nerve injury
brachial plexus injury
cerebral infarct
subclavian/IJ complications
pneumothorax
hemothorax
hydrothorax
chylothorax
neck hematoma
tracheal obstruction
ETT cuff perforation
tracheal perforation
femoral complications
bowel perforation
posas abscess
bladder perforation
higher incidence of infection
which site has a higher incidence of infection in central lines?
femoral
why does the femoral site have a higher incidence of infection?
due to anatomical location
independent of insertion skill
what percentage of central venous cannulation insertions experience some form of complication?
> 15%
what factors increase risk of complication for central venous lines
longer duration
incr disease severity
emergent vs elective
proceduralist experience
not using ultrasound
incr number of skin punctures
CLABSI
central line associated bloodstream infeciton
how many CLABSI per year?
80,000 CLABSI reports
how many deaths due to CLABSI per year
28,000 deaths due to CLABSI
avg cost per CLABSI case
$45,000 per case
$4b annually in US
IJ central line advantages
good external landmarks
improved success w/us
lower pneumo risk than subclavian
shallow = easier to control bleeding
straight course to SVC
easy to identify carotid
malpositioning cathether is rare
IJ central line disadvantages
more difficult to secure
higher infection risk than subclavian
higher risk of thrombosis than subclavian
IJ - carotid artery: anatomical relationship w/vein
medial and deep to IJ
IJ - carotid artery: error
insertion too medial
course of needle not directed at ipsilateral nipple
IJ - carotid artery: injury
hematoma
cerebral thromboembolism
airway obstruction
IJ - phrenic nerve: relationship with vein
passes on anterior surface of scalenus anterior
behind IJ
IJ - phrenic nerve: error
insertion too deep
IJ - phrenic nerve: injury
paralysis of ipsilateral hemidiaphragm
IJ - brachial plexus: relationship w/vein
separated from IJ by scalenus anterior
IJ - brachial plexus: error
insertion
- too deep
- too lateral
- too iferior
IJ - brachial plexus: injury
motor or sensory deficits in hand, arm, or shoulder
IJ - SCV: supraclavicular advantages
good external landmarks
most practical method of inserting central line during cardiopulmonary arrest?
SCV - supraclavicular
SCV: supraclavicular disadvantages
blind procedure
unable to compress bleeding vessels
SCV: infraclavicular advantages
good external landmarks
SCV: infraclavicular disadvantages
blind
unable to compress vessels
which pts should not received a SCV infraclavicular line?
children under 2
SCV - subclavian artery: relationship to vein
posterior
slightly superior to SCV
separated by scalenus anterior
10-15mm: adults
5-8mm: peds
SCV - subclavian artery: error
insertion too deep or lateral
SCV - subclavian artery: injury
hemorrhage
hematoma
hemothorax
SCV - brachial plexus: relationship to vein
posterior
separated by scalenus anterior and subclavian artery
20mm
SCV - brachial plexus: erro
insertion too deep or lateral
SCV - brachial plexus: injury
motor or sensory deficits in hand, arm, or shoulder
SCV - parietal pleura: anatomical relationship
contacts the posteroinferior side of SCV
medial to attachment of anterior scalenus muscle to first rib
SCV - parietal pleura: error
needle placed above or behind veins
penetration of both walls
SCV - parietal pleura: injury
pneumothorax
SCV - phrenic nerve: anatomical relationship
contacts the posteroinferior side of SCV
medial to attachment of anterior scalenus muscle to first rib
SCV - phrenic nerve: error
needle placed above or behind veins
penetration of both walls
SCV - phrenic nerve: injury
paralysis of ipsilateral hemidiaphragm
SCV - thoracic duct: anatomical relationship
anterior across scalenus
enters superior margin of SCV near IJ junction
SCV - thoracic duct: error
needle placed above or behind veins
penetration of both walls
SCV - thoracic duct: injury
soft tissue lymphedema
chylothorax
(left side)
NAVEL
Nerve
Artery
Vein
Empty
Lymphatics
what vein is NAVEL for?
femoral
the nerve is always ______ in femoral
lateral
lymphatics are always _____ in femoral
medial
femoral vein central line advantages
good external landmarks
useful alternative w/coagulopathy
which vein is useful for pts w/coagulopathy?
femoral
femoral vein central line disadvantages
difficult to secure for ambulatory pts
not reliable for CVP
highest risk of infection
higher risk of thrombus
femoral vein CVP would be
lower than expected
femoral - femoral artery: anatomical relationship
lateral to the vein in femoral triangle
femoral - femoral artery: error
needle passed to laterally
femoral - femoral artery: injury
hematoma
femoral - psoas muscle: anatomical relationship
directly posterior to artery and vein
femoral - psoas muscle: error
needle passed too deep
femoral - psoas muscle: injury
hematoma
psoas abscess
femoral - bowel: anatomical relationship
proximally deep to femoral vein
femoral - bowel: error
needle passes too deep
above inguinal ligament
femoral -bowel: injury
enterotomy
peritonitis
femoral - sinovial capsule of hip: anatomical relationship
deep to psoas
femoral - sinovial capsule: error
needle passed too deep
more common in small children
femoral - sinovial capsule: injury
arthritis
septic joint
what should you prep skin with during central line?
chlorohexidine
or
alcohol containing solution
where should you start prepping skin during central line?
start prep at anticipated insertion site and work outward
what are the last places to prep?
butt
axilla (armpit)
groin
introducer
allow for insertion of pulmonary artery catheter
multilumen central venous catheters
CVP
medications
adding catheter to central lines _______ flow rate
decreases
introducer is good for
fluid (high volume)
or
PAC
multilumen is good for
caustic meds
measurements
will a R IJ or L IJ require a longer catheter?
L IJ requires a 20 Fr (longer) catheter
central line kit components
gauze
pressure transducer tube
1% lido
3mL syringe w/filter
5mL syringe w/22g needle
aspiration needle
sledinger wire
suture locking clips
triple lumen catheter
dilator
18g needler w/catheter
scalpel
biopatch
needle safety cup
blood receptacle
needle and hemostat
what are 2 options to cannulate vein for central line?
20g needle w/angiocath
or
18g needle w/o angiocath
when are you looking for ectopy during central line?
when you are advancing seldinger wire
if you see ectopy during wire insertion what does that tell you?
that you have good far enough and are in the RA
what are you using the dilator on during central line?
the platysma
how much do you dilate?
2-3cm
what port does the wire come out of on triple lumen catheters?
central port
(brown)
what port does the wire come out of on double lumen catheters
distal port
Right supraclavicular insertion length
(Ht/10)-2 cm
Left supraclavicular insertion length
(Ht/10)+2cm
Right IJ insertion length
Ht/10
Left IJ insertion length
(Ht/10)+4cm
Right supraclavicular % in SVC
96%
Left supraclavicular % in SVC
97%
Right IJ % in SVC
90%
Left IJ % in SVC
94%
Right supraclavicular % in RA
4%
Left supraclavicular % in RA
2%
Right IJ % in RA
10%
Left IJ % in RA
5%
central line placement confirmation
blood aspirates easily
–all lumens
no sustained ectopy
bilateral breath sounds
no changes to ventilator
chest Xray
where should catheter tip be located for central line?
SVC RA junction
IJ central line positioning
turn pt head away from site
trendelenburg
why do you put pt in trendelenburg during central line cannulation?
promotes venous engorgement
decreases air embolism
which IJ is less tortuous?
Right is less tortuous
which cannulation approach is most common for the IJ?
central
central IJ cannulation approach
30 deg entry angle
aim toward ipsilateral nipple
SVC cannulation positioning
supine
neutral head/neck
adducted arms
slight trendelenburg
which SVC is preferred?
right
supraclavicular SVC needle placement
1cm lateral to clavicular head or sternocleidomastoid muscle
superior to clavicle
supraclavicular SVC insertion approach
10 degree
angled toward sternal notch/contralateral nipple
infraclavicular SVC insertion angle
parallel to floor
towards sternal notch
femoral cannulation positioning
supine
arms/legs adducted or neutral
which femoral vein should a right handed provider use?
Right
which femoral vein should a left handed provider use?
Lef
femoral vein cannulation angle
45 degrees
toward head
(cephalic direction)
femoral vein insertion location
1cm medial to artery
2cm inferior to inguinal ligament
