Transcript CENTRAL LINES

Central Venous Access
Mazen Kherallah, MD, FCCP
Indications
 Need for IV access and failure of peripheral access
 Peripheral access too painful or tenuous
 Long term IV access anticipated
 Medications indicated that are toxic to peripheral
veins
 Hemodynamic monitoring
 Volume resuscitation with large bore central lines
 Special procedure: Swan Ganz, dialysis,
plasmapheresis
Site Selection
Site
Pro’s
Subclavian  Large vessel
 Can tolerate
high flow
 Dressing easy
to maintain
 Less
restrictive for
patient
 Lowest sepsis
rate
7/21/2015
Con’s
 Close to lung
apex, risk of
pneumothorax
 Close to
subclavian
artery
 Hard to control
bleeding
Site Selection
Pro’s
Con’s
Large vessel
Easily located
Easy access
Short, straight
path to
superior vena
cava
 Decreased risk
of
pneumothorax
 Uncomfortable
for patient
 Difficult to
maintain
dressing
 Close to
carotid artery
 Easily
contaminated
 Difficult
maintenance
with trach or
neck injury
Site
Internal
Jugular
7/21/2015
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Site Selection
Site
Femoral
7/21/2015
Pro’s
 Easy access
 Large vessel
 Good access
during
resuscitation
Con’s
 Decreased
mobility
 Increased risk
of thrombosis,
phlebitis &
infection
 Easily
contaminated
 Close to
femoral artery
 Dressing
difficult to
maintain
Choice of Site
Subclavian
IJ
Femoral
Success Rate
90-95%
90-99%
90-95%
Arterial puncture
0.5-1%
10%
5-10%
Pneumothorax
1-5%
0-0.2%
0
Infectious rate
Lowest
Intermediate
Highest
Access during cardiac
arrest
2nd
3th
1st
Side of body
preference
Left: angle of
subclavian vein
Right: avoid thoracic
duct
None
Coagulopathy present
3th
2nd
1st
Hypovolemia present
1st: vein supported by
fibrous sheath
3th: vein collapses
2nd
Pacemaker
2nd
1st
3th
Anatomy of Great Vessels
Anatomy of Great Vessels
Anatomy of Great Vessels
Seldinger Technique
The Procedure
 Patient position:
 Patient is moved to the side of the bed so
physician would not lean over
 The bed is high enough so physician would
not have to stoop over
 Patient should be flat without a pillow,
Trendelenburg position if patient is
hypovolemic
 The head is turned away from the side of the
procedure
 Wrist restraints if necessary
The Procedure
 Skin preparation:
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Prepare before putting sterile gloves
Start at the center and work outward the
edges
Allow time for the sterilizing agent to dry
Disposable drape under the patient
Betadine or Chlorhexidine are acceptable
solution and have activity against gram
positive organisms
The Procedure
 Drape:
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Large enough
Handed sterilely by the assistant
Hole in the area of placement
 Prepare the tray:
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Handed sterilely by the assistant
Prepare the equipment before starting
 Anesthesia
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Use local anesthesia with lidocaine
YOUR ROLE AFTER THE INSERTION
 Dispose all sharps
 Place an occlusive sterile dressing
 Flush lumens to maintain patency
 Obtain a chest x-ray (ask for order if physician doesn’t
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mention it)
Monitor site for bleeding
Assess breath sounds
Assess circulation
Assess for hematoma
Document insertion, site, dressing and flushing
USING THE CENTRAL LINE
 Flush q shift, before and after use with NS. Some places
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also require heparin flush
Close clamps when not is use
Check P&P of facility, but usually fluids are changed
every 24 hours, tubing changed every 48-72 hours
Dressing is usually changed every 3 days
Line can be used for blood drawing - withdraw and
waste 10 cc, then withdraw blood for samples
If port becomes clotted, do not use - sometimes ports
can be opened up with urokinase (requires a doctor’s
order)
Complications
 Immediate
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Hemothorax
Pneumothorax
Arterial puncture
Vessel erosion
Nerve Injury
Dysrhythmias
Catheter malplacement
Embolus
Cardiac tamponade
Complications
 Delayed
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Dysrhythmias
Catheter malplacement
Vessel erosion
Embolus
Cardiac tamponade
Catheter related infection
Thrombosis
Vascular Erosion/Cardiac Tamponade
 Large vessel perforation is uncommon
 Vessel erosion more common with stiff
catheters, like dialysis catheters
 Cardiac tomponade occur mainly if the tip is
located in the RA
 Complication is fatal in 2/3 of cases
Air Embolism
 Air is sucked in through the catheter due to negative
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intrathoracic pressure during inspiration
Air can be pushed with flushing the catheter if it was
not pulled back before flushing
Complication is uncommon but can be fatal
Manifests with hypoxemia, cardiovascular collapse,
mental status changes and livedo reticularis
Place patient to left lateral position if suspected
Bleeding
 More common in patients with coagulopathy
 Easily controlled with femoral or IJ sites
 Place local pressure and correct
coagulopathy
Arterial Puncture and Cannulation
 If the artery is puncture local pressure is
applied for 3-5 minutes, observe for
hematoma formation
 If the artery is cannulated, pulsatile reflux of
blood can be noticed, blood gas analysis
reveals arterial.
 The catheter should not be used, and remove
it after coagulopathy is corrected if present
Thrombosis
 Sleeve fibrin surrounding the catheter (occurs
on the majority of catheters)
 Mural thrombus on the wall of the vein (1030% of catheters)
 Occlusive thrombus (1-10%)
Pneumothorax
 Most likely, pneumothorax is noticed after CXR is
seen, unless patient developed tension
pneumothorax with hypoxemia, cardiopulmonary
collapse and absent breath sound
 Small pneumothorax may be watched closely without
chest tube placement in the spontaneously breathing
patients
 Large pneumothorax requires chest tube placement
 Even small pneumothorax in patients on positive
pressure ventilation requires chest tube placement
Catheter-Related Sepsis
 Late complications
 Femoral > IJ > subclavian
 Triple lumen > single lumen
 Large bore > smaller catheter
 Sterility of procedure
 Number of hub manibulations
Basic Pressure Measurements from
Swan Ganz Catheter
Measurement
Normal range
Central venous pressure
<10 mm Hg
Right atrial pressure
<10 mmHg
Right ventricular pressure, systolic
15-30 mm Hg
Right ventricular pressure, diastolic
0-8 mm Hg
Pulmonary artery pressure, systolic
15-30 mm Hg
Pulmonary artery pressure, diastolic
5-16 mm Hg
Pulmonary artery pressure, mean
10-22
Pulmonary artery wedge pressure, mean
8-12
Hemodynamic Monitoring
Position of Transducer
Components of the Atrial Waves
Differences in CVP and PCWP
EKG correlation
Wave
EKG correlate
Description
A
In the P-R interval
RA contraction
C
End of QRS
V
Near end of T wave
Closure of the
tricuspid valve
Filling of the RA
X descent
Y descent
Downward slope
of a wave
Downward slope
of v wave
CVP Correlation with EKG
Normal CVP Tracing
Reading the mean of an A wave
22+10/2=16
Spontaneous Breathing
Reading CVP
Spontaneous Breathing
Insp./Exp. Ratio in Rapid Breathing
Spontaneous Breathing
Insp./Exp. Ratio in Rapid Breathing
Hemodynamic Monitoring
Central Venous Pressure: normal 4-10
 Increased CVP:
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Right heart failure
Right myocardial infarction
Cardiac tomponade
Tricuspid insufficiency
Left to right shunt
Pulmonary emboli
COPD and cor pulmonale
ARDS
Excess fluid
Tricuspid stenosis
 Decreased CVP
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hypovolumia
Decreased venous return
Excessive veno or
vasodilation
Shock
Central Venous Pressure Tracings
 Normal EKG tracing
and right atrial pressure
waveform
 Atrial fibrillation
 Atrioventricular
dissociation
Central Venous Pressure Tracings
 Normal EKG and right
atrial waveforms
 Tricuspid stenosis
 Mild to moderate
tricuspid insufficiency
 Severe tricuspid
insufficiency
 Constrictive pericarditis
Large A wave Secondary to Loss of Atrioventricular Synchrony
Simultaneous Atrial and Ventricular Contraction
Loss of A Wave
Atrial Fibrillation