Session 27. Central Lines - Old School Flashcards by Kira Harms

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

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ScvO2

central venous oxygenation

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central venous oxygenation

oxygen tension in venous blood after going to the body

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

IV drug abusers
major burns
severe dehydration
severe morbid obesity

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

PICC

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where can PICC lines be placed?

brachial
axilary
basilic

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central line relative CI

tumors
clots
tricuspid valve vegetation
(endocarditis)
burns

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when are burns CI to placing central line

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

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central line absolute CI

abx allergy
hx of severe anatomical distortion of access site

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what type of abx are found in central line catheters

tetracycline
rifampin
chlorhexidine

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when can you bypass a relative CI for central line?

in an emergency

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IJ central line relative CI

cervical trauma w/swelling
cervical instability

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subclavian central line relative CI

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

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femoral central line relative CI

intraabdominal hemorrhage
pelvis injury
know/suspect DVT

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central line general complications

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

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central line infectious complications

bloodstream infection
generalized sepsis
septic arthritis
osteomyelitis
cellulitis at insertion site

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central line thrombotic complications

pulmonary embolism
venous thrombosis

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neurologic complications

phrenic nerve injury
brachial plexus injury
cerebral infarct

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subclavian/IJ complications

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

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femoral complications

bowel perforation
posas abscess
bladder perforation
higher incidence of infection

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

femoral

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

due to anatomical location
independent of insertion skill

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

> 15%

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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

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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

Left supraclavicular % in RA

Right IJ % in RA

10%

Left IJ % in RA

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

Session 27. Central Lines - Old School Flashcards

(127 cards)