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Sp: Sim Lab 1 > Session 27. Central Lines - Old School > Flashcards

Session 27. Central Lines - Old School Flashcards

1
Q

central line indications

A

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

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2
Q

ScvO2

A

central venous oxygenation

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3
Q

central venous oxygenation

A

oxygen tension in venous blood after going to the body

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4
Q

what pts might need a central line to establish venous access?

A

IV drug abusers
major burns
severe dehydration
severe morbid obesity

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5
Q

what type of line can be inserted for prolonged IV access?

A

PICC

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6
Q

where can PICC lines be placed?

A

brachial
axilary
basilic

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7
Q

central line relative CI

A

tumors
clots
tricuspid valve vegetation
(endocarditis)
burns

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8
Q

when are burns CI to placing central line

A

after 3 days due to higher risk of bacterial colonization and infection

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9
Q

central line absolute CI

A

abx allergy
hx of severe anatomical distortion of access site

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10
Q

what type of abx are found in central line catheters

A

tetracycline
rifampin
chlorhexidine

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11
Q

when can you bypass a relative CI for central line?

A

in an emergency

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12
Q

IJ central line relative CI

A

cervical trauma w/swelling
cervical instability

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13
Q

subclavian central line relative CI

A

clavicular or 1st rib sx/trauma
cannulate ispilateral SCV to that of chest wall traum

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14
Q

femoral central line relative CI

A

intraabdominal hemorrhage
pelvis injury
know/suspect DVT

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15
Q

central line general complications

A

arterial puncture
hematoma
vessel injury (fistula)
air embolism
catheter embolus
cardiac dysrhythmia
thrombosis
catheter musplacement
lost seldinger wire
catheter knotting

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16
Q

central line infectious complications

A

bloodstream infection
generalized sepsis
septic arthritis
osteomyelitis
cellulitis at insertion site

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17
Q

central line thrombotic complications

A

pulmonary embolism
venous thrombosis

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18
Q

neurologic complications

A

phrenic nerve injury
brachial plexus injury
cerebral infarct

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19
Q

subclavian/IJ complications

A

pneumothorax
hemothorax
hydrothorax
chylothorax
neck hematoma
tracheal obstruction
ETT cuff perforation
tracheal perforation

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20
Q

femoral complications

A

bowel perforation
posas abscess
bladder perforation
higher incidence of infection

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21
Q

which site has a higher incidence of infection in central lines?

A

femoral

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22
Q

why does the femoral site have a higher incidence of infection?

A

due to anatomical location
independent of insertion skill

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23
Q

what percentage of central venous cannulation insertions experience some form of complication?

A

> 15%

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24
Q

what factors increase risk of complication for central venous lines

A

longer duration
incr disease severity
emergent vs elective
proceduralist experience
not using ultrasound
incr number of skin punctures

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25
Q

CLABSI

A

central line associated bloodstream infeciton

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26
Q

how many CLABSI per year?

A

80,000 CLABSI reports

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27
Q

how many deaths due to CLABSI per year

A

28,000 deaths due to CLABSI

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28
Q

avg cost per CLABSI case

A

$45,000 per case

$4b annually in US

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29
Q

IJ central line advantages

A

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

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30
Q

IJ central line disadvantages

A

more difficult to secure
higher infection risk than subclavian
higher risk of thrombosis than subclavian

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31
Q

IJ - carotid artery: anatomical relationship w/vein

A

medial and deep to IJ

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32
Q

IJ - carotid artery: error

A

insertion too medial
course of needle not directed at ipsilateral nipple

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33
Q

IJ - carotid artery: injury

A

hematoma
cerebral thromboembolism
airway obstruction

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34
Q

IJ - phrenic nerve: relationship with vein

A

passes on anterior surface of scalenus anterior
behind IJ

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35
Q

IJ - phrenic nerve: error

A

insertion too deep

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36
Q

IJ - phrenic nerve: injury

A

paralysis of ipsilateral hemidiaphragm

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37
Q

IJ - brachial plexus: relationship w/vein

A

separated from IJ by scalenus anterior

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38
Q

IJ - brachial plexus: error

A

insertion
- too deep
- too lateral
- too iferior

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39
Q

IJ - brachial plexus: injury

A

motor or sensory deficits in hand, arm, or shoulder

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40
Q

IJ - SCV: supraclavicular advantages

A

good external landmarks

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41
Q

most practical method of inserting central line during cardiopulmonary arrest?

A

SCV - supraclavicular

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42
Q

SCV: supraclavicular disadvantages

A

blind procedure
unable to compress bleeding vessels

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43
Q

SCV: infraclavicular advantages

A

good external landmarks

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44
Q

SCV: infraclavicular disadvantages

A

blind
unable to compress vessels

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45
Q

which pts should not received a SCV infraclavicular line?

A

children under 2

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46
Q

SCV - subclavian artery: relationship to vein

A

posterior
slightly superior to SCV
separated by scalenus anterior
10-15mm: adults
5-8mm: peds

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47
Q

SCV - subclavian artery: error

A

insertion too deep or lateral

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48
Q

SCV - subclavian artery: injury

A

hemorrhage
hematoma
hemothorax

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49
Q

SCV - brachial plexus: relationship to vein

A

posterior
separated by scalenus anterior and subclavian artery
20mm

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50
Q

SCV - brachial plexus: erro

A

insertion too deep or lateral

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51
Q

SCV - brachial plexus: injury

A

motor or sensory deficits in hand, arm, or shoulder

52
Q

SCV - parietal pleura: anatomical relationship

A

contacts the posteroinferior side of SCV
medial to attachment of anterior scalenus muscle to first rib

53
Q

SCV - parietal pleura: error

A

needle placed above or behind veins
penetration of both walls

54
Q

SCV - parietal pleura: injury

A

pneumothorax

55
Q

SCV - phrenic nerve: anatomical relationship

A

contacts the posteroinferior side of SCV
medial to attachment of anterior scalenus muscle to first rib

56
Q

SCV - phrenic nerve: error

A

needle placed above or behind veins
penetration of both walls

57
Q

SCV - phrenic nerve: injury

A

paralysis of ipsilateral hemidiaphragm

58
Q

SCV - thoracic duct: anatomical relationship

A

anterior across scalenus
enters superior margin of SCV near IJ junction

59
Q

SCV - thoracic duct: error

A

needle placed above or behind veins
penetration of both walls

60
Q

SCV - thoracic duct: injury

A

soft tissue lymphedema
chylothorax

(left side)

61
Q

NAVEL

A

Nerve
Artery
Vein
Empty
Lymphatics

62
Q

what vein is NAVEL for?

A

femoral

63
Q

the nerve is always ______ in femoral

A

lateral

64
Q

lymphatics are always _____ in femoral

A

medial

65
Q

femoral vein central line advantages

A

good external landmarks
useful alternative w/coagulopathy

66
Q

which vein is useful for pts w/coagulopathy?

A

femoral

67
Q

femoral vein central line disadvantages

A

difficult to secure for ambulatory pts
not reliable for CVP
highest risk of infection
higher risk of thrombus

68
Q

femoral vein CVP would be

A

lower than expected

69
Q

femoral - femoral artery: anatomical relationship

A

lateral to the vein in femoral triangle

70
Q

femoral - femoral artery: error

A

needle passed to laterally

71
Q

femoral - femoral artery: injury

A

hematoma

72
Q

femoral - psoas muscle: anatomical relationship

A

directly posterior to artery and vein

73
Q

femoral - psoas muscle: error

A

needle passed too deep

74
Q

femoral - psoas muscle: injury

A

hematoma
psoas abscess

75
Q

femoral - bowel: anatomical relationship

A

proximally deep to femoral vein

76
Q

femoral - bowel: error

A

needle passes too deep
above inguinal ligament

77
Q

femoral -bowel: injury

A

enterotomy
peritonitis

78
Q

femoral - sinovial capsule of hip: anatomical relationship

A

deep to psoas

79
Q

femoral - sinovial capsule: error

A

needle passed too deep

more common in small children

80
Q

femoral - sinovial capsule: injury

A

arthritis
septic joint

81
Q

what should you prep skin with during central line?

A

chlorohexidine
or
alcohol containing solution

82
Q

where should you start prepping skin during central line?

A

start prep at anticipated insertion site and work outward

83
Q

what are the last places to prep?

A

butt
axilla (armpit)
groin

84
Q

introducer

A

allow for insertion of pulmonary artery catheter

85
Q

multilumen central venous catheters

A

CVP
medications

86
Q

adding catheter to central lines _______ flow rate

A

decreases

87
Q

introducer is good for

A

fluid (high volume)
or
PAC

88
Q

multilumen is good for

A

caustic meds
measurements

89
Q

will a R IJ or L IJ require a longer catheter?

A

L IJ requires a 20 Fr (longer) catheter

90
Q

central line kit components

A

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

91
Q

what are 2 options to cannulate vein for central line?

A

20g needle w/angiocath
or
18g needle w/o angiocath

92
Q

when are you looking for ectopy during central line?

A

when you are advancing seldinger wire

93
Q

if you see ectopy during wire insertion what does that tell you?

A

that you have good far enough and are in the RA

94
Q

what are you using the dilator on during central line?

A

the platysma

95
Q

how much do you dilate?

A

2-3cm

96
Q

what port does the wire come out of on triple lumen catheters?

A

central port
(brown)

97
Q

what port does the wire come out of on double lumen catheters

A

distal port

98
Q

Right supraclavicular insertion length

A

(Ht/10)-2 cm

99
Q

Left supraclavicular insertion length

A

(Ht/10)+2cm

100
Q

Right IJ insertion length

A

Ht/10

101
Q

Left IJ insertion length

A

(Ht/10)+4cm

102
Q

Right supraclavicular % in SVC

A

96%

103
Q

Left supraclavicular % in SVC

A

97%

104
Q

Right IJ % in SVC

A

90%

105
Q

Left IJ % in SVC

A

94%

106
Q

Right supraclavicular % in RA

A

4%

107
Q

Left supraclavicular % in RA

A

2%

108
Q

Right IJ % in RA

A

10%

109
Q

Left IJ % in RA

A

5%

110
Q

central line placement confirmation

A

blood aspirates easily
–all lumens
no sustained ectopy
bilateral breath sounds
no changes to ventilator
chest Xray

111
Q

where should catheter tip be located for central line?

A

SVC RA junction

112
Q

IJ central line positioning

A

turn pt head away from site
trendelenburg

113
Q

why do you put pt in trendelenburg during central line cannulation?

A

promotes venous engorgement
decreases air embolism

114
Q

which IJ is less tortuous?

A

Right is less tortuous

115
Q

which cannulation approach is most common for the IJ?

A

central

116
Q

central IJ cannulation approach

A

30 deg entry angle
aim toward ipsilateral nipple

117
Q

SVC cannulation positioning

A

supine
neutral head/neck
adducted arms
slight trendelenburg

118
Q

which SVC is preferred?

A

right

119
Q

supraclavicular SVC needle placement

A

1cm lateral to clavicular head or sternocleidomastoid muscle
superior to clavicle

120
Q

supraclavicular SVC insertion approach

A

10 degree
angled toward sternal notch/contralateral nipple

121
Q

infraclavicular SVC insertion angle

A

parallel to floor
towards sternal notch

122
Q

femoral cannulation positioning

A

supine
arms/legs adducted or neutral

123
Q

which femoral vein should a right handed provider use?

A

Right

124
Q

which femoral vein should a left handed provider use?

A

Lef

125
Q

femoral vein cannulation angle

A

45 degrees
toward head
(cephalic direction)

126
Q

femoral vein insertion location

A

1cm medial to artery
2cm inferior to inguinal ligament

127
Q
A

Sp: Sim Lab 1 (23 decks)

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