Transcript Central Venous Lines and Thoracic Drainage

Central Venous Lines and
Thoracic Drainage
Division of Cardiothoracic Surgery
UWI Mona
Central Venous Lines: Why?
To monitor / ascertain hydration status
 To administer fluids / nutrition
 To administer medications
 To gain access to the right side of the
heart and pulmonary arterial tree

Anatomy of Central Venous
Access
CV Lines: Multiple Access Sites
Access Sites, continued

Central venous lines
can also be placed
by gaining access
from peripheral
veins (basilic,
cephalic, femoral)
 Peripherally-inserted
central catheter
 “PICC” lines
Implantation Techniques
Sterile Technique
 Seldinger Method

Placement of needle inside vein. Guide wire
through needle into vein, needle removed.
Dilator over guide wire, dilator removed, wire
left in vein. Catheter over guide wire into vein,
guide wire removed, catheter left in situ.
Safest, surest method of cannulation of
vessels yet devised.
Seldinger Technique
Other Techniques:

Open (Venesection)

Catheter-thru-Needle
Other Techniques, con’td

Catheter-over-Needle

Catheter-thru-cannula
Complications of CV lines

Incorrect puncture
– Into tissues
– With perforation of vessel (out the other
side)
– With arterial damage
– Into pleural cavity  pneumo,
haemothorax
– With nerve damage (brachial plexus)
Complications, con’td

Incorrect Catheter Position
– In another vein (non-central, ascending)
– Lumen openings outside venous lumen
– Catheter positioned too far into right atrium
 incorrect pressure interpretation
 cardiac dysrhythmias
 cardiac perforation
Complications, con’td

Embolism
– Catheter Embolism
– Guidewire Embolism
– Air Embolism
Treatment may need to be immediate or
adopt “wait and see” policy
Other Complications

Thrombosis

Local Infection

Local Haemorrhage

Disseminated Infection
– (catheter-related septicaemia)
Hydration Status and Monitoring

In general:
Central Venous Pressure 5 to 15 mmHg
< 5 mmHg  HYPOVOLEMIA
> 15 mmHg HYPERVOLEMIA
THIS IS ONLY TRUE FOR NORMAL,
IDEALIZED INDIVIDUAL
Fluid Status / Monitoring
Ill patients are much more variable
 An ill patient may be hypervolemic with
a CVP of 10, or may be hypovolemic
with a CVP of 16
 Use of the CV pressure monitoring line
allows for close and precise evaluation
of the patients’ intravascular volume
status

A Typical CV catheter:

One or more (up to
3) lumina for
simultaneous
pressure monitoring
and fluid / drug
administration
Swan-Ganz Catheter

Inserted into central
vein via Seldinger
technique, then
advanced into
pulmonary artery
branch using
pressure curves to
guide placement
Swan-Ganz Catheter

When advanced into PA, blowing up of
balloon gives information as to the
LEFT ATRIAL PRESSURE, which
relates directly to the filling pressure of
the left ventricle, and from which
detailed calculations of CARDIAC
OUTPUT can be derived (thermodilution
technique)
Swan-Ganz:
Pressures during insertion
CVP, Swan-Ganz, Chest Tubes in
situ:
CV lines: Nutrition, Meds,
Access to R. Heart

Nutrition: TPN (total parenteral nutrition)

Medications: Chemotherapy, vasosclerosant meds

Access: eg. Pacemaker wires
Cardiac Biopsy
Pacemaker in situ (via CV access)
Chest Intubation
(Tube Thoracostomy) : Why?

A procedure which becomes necessary
when the pleural space contains air or
fluid (blood, chyle, pus, bile, gastric
contents, bowel contents, other fluids) in
order that those abnormal contents can
be drained and the underlying lung be
allowed to re-expand to fill the pleural
cavity
Pleural space is “potential space”
Tube Thoracostomy: When?

Following trauma (accidental, operative)

Following spontaneous pneumothorax

Following the development of a pusfilled chest after pneumonia or
penetrating trauma (empyaema
thoracis)
Chest Tube: How does it work?
Fluid/Air drains into 1st bottle. Tube under H20 acts as a
one-way valve fluid/air out, but not back in. Second
bottle is a fluid trap. Third bottle allows for safe application
of suction
Fluid in Pleural Space:
Pus = Empyaema Thoracis
Blood = Haemothorax
Blood + Air = Haemopneumothorax
Chest Intubation: How?
Chest Intubation: The tube
Sites for Chest
Intubation
NB. Unusual sites
are dictated by location
of fluid collections
Incise

Make
a
linear
incision along the rib,
one interspace below
the site of insertion of
the tube
Dissect

Insert a curved
clamp and tunnel
superiorly to the
interspace that is to
be entered Avoid the
neurovascular
bundle at the inferior
margin of the rib
Puncture



Gently but forcibly
puncture through the
intercostal muscles
and parietal pleura.
A gush of air and/or
blood will exit through
the wound.
Avoid injuring the
lung tissue when
puncturing the pleura
Insertion

Insert a finger into
the pleural space to
identify and
separate pleural
adhesions With the
clamp, grasp the tip
of the chest tube
and advance it into
the thorax
Secure the tube

Direct the catheter
posteriorly, superiorly

Secure the tube
– Use an 0 silk suture
into the skin through
the incision. Come out
through the opposite
side. Then, wrap the
suture around the tube
several times and tie it
securely in place.
Chest Intubation: Results can be
dramatic and life saving!
Chest Tubes: Caveats

Excessively rapid drainage of fluid/air
can result in too rapid re-expansion of
ipsilateral lung leading to:
RE-EXPANSION PULMONARY
OEDEMA (not well understood)

NEVER clamp a chest tube, unless
directed to do so by a chest surgeon!!
Conclusions
Central venous line insertion and chest
intubation are two essential clinical skills
 Both procedures are highly technical
and may have complications, but
modern techniques have greatly
reduced adverse events
