Chapter 22 The Role of Ultrasound in Central Access Device Placement

Question 1

inadvertent release of air or gas into the venous system

Answer 1

air embolism

Question 2

preexisting veins that enlarge to take flow from neighboring but occluded vessels

Answer 2

collateral veins

Question 3

an abnormal connection or passageway between two organs or vessels; may be caused by trauma or intentionally for therapeutic purposes

Answer 3

fistula

Question 4

The brightness of an ultrasound image, which can be manipulated on most devices

Answer 4

gain

Question 5

a hydrophilic guidewire

Answer 5

glidewire

Question 6

A Nitinol or stainless steel wire used to support sheath or catheter exchanges and to predict vessel patency; measured in diameter and length

Answer 6

guidewire

Question 7

leaking of intravenous fluid from a catheter into the tissue surrounding the vein

Answer 7

infiltration

Question 8

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

Answer 8

intima

Question 9

small needles are wires used to make the initial access into a target

Answer 9

microintroducer

Question 10

A sheath that is perforated along the long axis, allowing the device to be split for removal from a catheter

Answer 10

peel-away sheath

Question 11

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

Answer 11

peripherally inserted central catheter (PICC)

Question 12

Collection of air in the pleural space (between the lung and the chest wall)

Answer 12

pneumothorax

Question 13

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

Answer 13

sheath

Question 14

Narrowing of a vein or an artery because of disease or trauma

Answer 14

stenosis

Question 15

Different reasons for venous access

Answer 15

intravenous antibiotic therapy
central venous pressure monitoring and sampling
hemodialysis
chemotherapy
total parenteral nutrition

Question 16

catheters that allow clinicians to infuce medications and blood components, obtain blood samples, and deliver other exchange therapies

Answer 16

Vascular access devices

Question 17

catheters placed such that the terminal tip of the catheter resides in a central vein, most often the superior vena cava

Answer 17

central VAD

Question 18

single- or dual- lumen devices with the tip remaining in the peripheral vein and do not cross into the axillary vein

Answer 18

midline catheteres

Question 19

Most common places for central VAD placement

Answer 19

peripheral
basilic
cephalic
brachial
subclavian
internal jugular
external jugular

Question 20

The central VAD catheter typically resides ______

Answer 20

in the distal third of the SVC or slightly deeper at the atriocaval junction

Question 21

flow rate of atriocaval junction

Answer 21

2000 mL/min

Question 22

Three categories of VADS

Answer 22

nontunneled devices
tunneled devices
implanted ports

Question 23

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

Answer 23

nontunneled central VADs

Question 24

critical care catheters
temporary dialysis and apheresis catheters
small bore polyurethane or silicone catheters
PICCS

Answer 24

nontunneled central VADs

Question 25

secured at the puncture site with sutures, subcuteaneous securement devices, or adhesive securement devices

Answer 25

nontunneled central VADs

Question 26

placed via a central vein with their tip residing at the atriocaval junction or in the distal third of the SVC

Answer 26

Tunneled VADs

Question 27

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

Answer 27

tunneled VADs

Question 28

infusions long term dialysis or apheresis

Answer 28

tunneled VADs

Question 29

VADs with a catheter segment attached to a plastic or titanium reservoir. The entire system is placed under the skin.

Answer 29

implanted ports

Question 30

patients who require intermittent therapy such as weekly or monthly

Answer 30

implanted ports

Question 31

dominant superficial vein of the upper extremity

Answer 31

basilic vein

Question 32

Basilic vein blood flow velocity

Answer 32

80 mL/min

Question 33

vein of first choice for placement of PICCs

Answer 33

basilic vein

Question 34

drains directly into axillary vein, which becomes SVC as it enters chest

Answer 34

basilic vein

Question 35

smallest major vein in upper extremity

Answer 35

cephalic vein

Question 36

blood flow velocity of cephalic vein

Answer 36

30 mL/min

Question 37

least preferred choice for VAD placement in upper extremity

Answer 37

cephalic vein

Question 38

Most common sites for central venous access

Answer 38

IJVs SCVs

Question 39

The ____ IJV is more preferred for VAD placement because it has a straighter course to the heart

Answer 39

right

Question 40

drain blood from the face and the neck

Answer 40

EJV and anterior jugular vein

Question 41

joins IJV at confluence of SCVs and brachiocephalic veins

Answer 41

EJV

Question 42

____ are commonly used to attain central venous access, located in the chest, usually directly under the clavicle

Answer 42

SCVs

Question 43

terminate in brachiocephalic veins join to form:

Answer 43

superior vena cava

Question 44

The IJV is located ____ and _____ to CCA

Answer 44

anterior lateral

Question 45

located in groin medial to CFA

Answer 45

Common femoral vein

Question 46

drain blood from lower extremities into external iliac veins

Answer 46

common femoral veins

Question 47

most often used for central venous access in emergent situations

Answer 47

common femoral veins

Question 48

VAD sonographic appearance

Answer 48

parallel hyperechoic linear structure

Question 49

occurs each time a vein is accessed

Answer 49

vein damage

Question 50

3 layers of vein

Answer 50

intima media adventitia

Question 51

innermost lining of vein, single layer of endothelial cells

Answer 51

tunica intima

Question 52

leaking of fluid from a catheter into tissue around vein

Answer 52

infiltration

Question 53

may occur if catheter passes through wall of vein or slips out of vein

Answer 53

infiltration

Question 54

initial needle placed through both walls of vein into neighboring artery

Answer 54

arterial venous fistula

Question 55

occurs when access needle is directed to a neighboring structure

Answer 55

nontarget puncture

Question 56

one of the most serious and potentially life threatening complications of central venous catheterization

Answer 56

pneumothorax

Question 57

occurs when air enters the venous system via the needle, sheath, or device; can result in respiratory compromise or death

Answer 57

air embolism

Question 58

typically occur when guidewires are advanced into heart, triggering hearts conduction system

Answer 58

cardiac arrhythmias

Question 59

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

Answer 59

d

Question 60

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

Answer 60

c

Question 61

Why is the aortocaval junction a desirable location for placement of the VAD catheter tip?

Answer 61

flow rates are around 2000 mL/min

Question 62

What is a type of VAD that is placed percuteaneously into a central or peripheral vein with its end secured at the puncture site?

Answer 62

nontunneled central VAD

Question 63

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

Answer 63

a

Question 64

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

Answer 64

d

Question 65

Implanted ports are typically used in patients who require therapy at what rate?

Answer 65

weekly

Question 66

Which of the following veins is typically the first choice for placement of peripherally inserted central catheters?

Answer 66

basilic vein

Question 67

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

Answer 67

b

Question 68

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)

Answer 68

d

Question 69

Which jugular vein is preferred for central VAD placement?

Answer 69

right internal jugular vein

Question 70

Where is the internal jugular vein typically located in relation to the common carotid artery?

Answer 70

anterolateral

Question 71

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

Answer 71

b

Question 72

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

Answer 72

d

Question 73

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

Answer 73

c

Question 74

How is confirmation of tip placement of a vascular access device typically made?

Answer 74

chest x-ray

Question 75

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?

Answer 75

vein damage with thrombosis

Question 76

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

Answer 76

a

Question 77

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

Answer 77

d

Question 78

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

Answer 78

b

Question 79

Ultrasound is being incorporated increasingly to attain access and place vascular access devices in patients with ______.

Answer 79

difficult access

Question 80

More centrally located target veins include the ______ and internal _____ veins.

Answer 80

subclavian veins jugular

Question 81

The catheter tip of a vascular access device typically resides in the distal third of the ____ at the atriocaval junction

Answer 81

SVC

Question 82

A vascular access device designed to remain in place long term would be a(n) _____

Answer 82

nontunneled central vascular access device

Question 83

Vascular access devices with a catheter segment attached to a plastic or titanium reservoir are _____

Answer 83

implanted ports

Question 84

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

Answer 84

inadvertent arterial puncture

Question 85

When accessing the central veins for central VAD placement, the ____ internal jugular vein is preferred because of a straighter course to the heart

Answer 85

right

Question 86

Ultrasound allows for _____ assessment of the internal jugular vein before VAD placement as well as dynamic guidance during vein puncture/

Answer 86

anatomic

Question 87

Using ultrasound guidance during vein puncture can reduce failure of catheter placement as well as complication rates related to ______

Answer 87

insertion

Question 88

When accessing the internal jugular vein, it is important to identify the ______ before attempting cannulation to avoid serious injury

Answer 88

common carotid artery

Question 89

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.

Answer 89

chronic renal insufficiency or chronic kidney disease

Question 90

The ______ veins are typically only used for venous access in emergent situations and in patients in whom other potential access veins are occluded.

Answer 90

common femoral

Question 91

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.

Answer 91

compressability

Question 92

On ultrasound, the VAD appears in the lumen of the vein and produces a(n) ______ structure on the image.

Answer 92

parallel hyperechoic linear

Question 93

The presence of ______ veins upon physical examination should alert the clinician to potential difficulties in successful placement of VADs.

Answer 93

collateral

Question 94

Thrombosis and arteriovenous fistula formation are examples of complications due to _____.

Answer 94

vein damage

Question 95

To minimize the impact of ______ puncture, a small access needle should be used.

Answer 95

nontarget

Question 96

Difficult or traumatic VAD insertion, hematologic disorders, and concurrent treatment with certain medications all increase the risk of ______ during VAD placement

Answer 96

bleeding

Question 97

Using valved sheaths, performing exchange maneuvers efficiently, and assuring that catheter lumens are flushed, secured, and locked will decrease the risk of _____.

Answer 97

air embolism

Question 98

When advancing guidewires into the heart during VAD placement, transient, asymptomatic, ______ often occur.

Answer 98

cardiac arrhythmias