CENTRAL LINES CENTRAL LINES AND AND

ARTERIAL LINESARTERIAL LINES

SHARON HARVEYSHARON HARVEY

26/01/0426/01/04

LEARNING OUTCOMESLEARNING OUTCOMESTHE STUDENT SHOULD BE ABLE THE STUDENT SHOULD BE ABLE

TO:-TO:- IDENTIFY A CENTRAL LINE AND ARTERIAL IDENTIFY A CENTRAL LINE AND ARTERIAL LINELINE

DISCUSS THE INDICATIONS FOR CENTRAL DISCUSS THE INDICATIONS FOR CENTRAL LINES AND ARTERIAL LINESLINES AND ARTERIAL LINES

DISCUSS THE COMPLICATIONS DISCUSS THE COMPLICATIONS ASSOCIATED WITH CENTRAL LINES AND ASSOCIATED WITH CENTRAL LINES AND ARTERIAL LINESARTERIAL LINES

ARTICULATE THE MANAGEMENT OF A ARTICULATE THE MANAGEMENT OF A PATIENT WITH A CENTRAL LINE AND/OR PATIENT WITH A CENTRAL LINE AND/OR ARTERIAL LINEARTERIAL LINE

WHAT IS A CENTRAL LINEWHAT IS A CENTRAL LINE

It is a catheter that It is a catheter that provides venous provides venous access via the access via the superior vena cava superior vena cava or right atriumor right atrium

COMMON CENTRAL LINE COMMON CENTRAL LINE INSERTION SITESINSERTION SITES

Right internal Right internal jugularjugular

left internal jugularleft internal jugular right subclavianright subclavian left subclavianleft subclavian femoral (as a last femoral (as a last

resort)resort)

Or peripherally Or peripherally inserted central inserted central catheters (PICC) catheters (PICC) which are inserted which are inserted via the antecubital via the antecubital veins (basilic vein is veins (basilic vein is the best) in the arm the best) in the arm and is advanced and is advanced into the central into the central veinsveins

TYPES OF CENTRAL LINETYPES OF CENTRAL LINE

SINGLE LUMENSINGLE LUMEN TRIPLE LUMENTRIPLE LUMEN QUADRUPLE QUADRUPLE

LUMENLUMEN QUINTUPLE LUMENQUINTUPLE LUMEN

CENTRAL LINESCENTRAL LINES

Indications for CVP lines are:-Indications for CVP lines are:- fluid resuscitationfluid resuscitation Parenteral feedingParenteral feeding measurement of central venous measurement of central venous

pressurepressure poor venous accesspoor venous access administration of irritant drugsadministration of irritant drugs

COMPLICATIONS COMPLICATIONS FOLLOWING CVP LINE FOLLOWING CVP LINE

INSERTIONINSERTION Malposition of the Malposition of the

cathetercatheter haematomahaematoma arterial puncturearterial puncture pneumothoraxpneumothorax haemorrhagehaemorrhage sepsissepsis air emboliair emboli

Catheter embolismCatheter embolism ThrombosisThrombosis HaemothoraxHaemothorax Cardiac tamponadeCardiac tamponade Cardiac Cardiac

arrhythmiasarrhythmias

CENTRAL VENOUS CENTRAL VENOUS PRESSUREPRESSURE

WHAT IS CENTRAL VENOUS WHAT IS CENTRAL VENOUS PRESSUREPRESSURE

IS THE PRESSURE WITHIN THE IS THE PRESSURE WITHIN THE SUPERIOR VENA CAVA OR THE RIGHT SUPERIOR VENA CAVA OR THE RIGHT ATRIUMATRIUM

CVP READINGS ARE USED:-CVP READINGS ARE USED:-

TO SERVE AS A GUIDE TO FLUID TO SERVE AS A GUIDE TO FLUID BALANCE IN CRITICALLY ILL BALANCE IN CRITICALLY ILL PATIENTSPATIENTS

TO ESTIMATE THE CIRCULATING TO ESTIMATE THE CIRCULATING BLOOD VOLUMEBLOOD VOLUME

TO ASSIST IN MONITORING TO ASSIST IN MONITORING CIRCULATORY FAILURECIRCULATORY FAILURE

CENTRAL VENOUS CENTRAL VENOUS PRESSURE MONITORINGPRESSURE MONITORING

THIS IS A HELPFUL TOOL IN THE THIS IS A HELPFUL TOOL IN THE ASSESSMENT OF CARDIAC FUNCTION, ASSESSMENT OF CARDIAC FUNCTION, CIRCULATING BLOOD VOLUME, VASCULAR CIRCULATING BLOOD VOLUME, VASCULAR TONE AND THE PATIENT’S RESPONSE TO TONE AND THE PATIENT’S RESPONSE TO TREATMENTTREATMENT

HOWEVER, CVP SHOULD NOT BE HOWEVER, CVP SHOULD NOT BE INTERPRETED SOLELY BUT IN CONJUNCTION INTERPRETED SOLELY BUT IN CONJUNCTION WITH OTHER SYSTEMIC MEASUREMENTS, AS WITH OTHER SYSTEMIC MEASUREMENTS, AS ISOLATED CVP MEASUREMENTS CAN BE ISOLATED CVP MEASUREMENTS CAN BE MISLEADINGMISLEADING

METHODS OF CVP METHODS OF CVP MONITORINGMONITORING

There are two methods of CVP There are two methods of CVP monitoringmonitoring manometer system:manometer system: enables enables

intermittent readings and is less intermittent readings and is less accurate than the transducer systemaccurate than the transducer system

transducer system:transducer system:enables continuous enables continuous readings which are displayed on a readings which are displayed on a monitor.monitor.

MONITORING WITH MONITORING WITH TRANSDUCERSTRANSDUCERS

Transducers enable the pressure Transducers enable the pressure readings from invasive monitoring to be readings from invasive monitoring to be displayed on a monitordisplayed on a monitor

To maintain patency of the cannula a bag To maintain patency of the cannula a bag of normal saline or heparinised saline of normal saline or heparinised saline should be connected to the transducer should be connected to the transducer tubing and kept under continuous tubing and kept under continuous pressure of 300mmHg thus facilitating a pressure of 300mmHg thus facilitating a continuous flush of 3mls/hrcontinuous flush of 3mls/hr

PROCEDURE FOR CVP MEASUREMENT PROCEDURE FOR CVP MEASUREMENT USING A TRANSDUCERUSING A TRANSDUCER

EXPLAIN THE PROCEDURE TO THE PATIENTEXPLAIN THE PROCEDURE TO THE PATIENT ENSURE THE LINE IS PATENTENSURE THE LINE IS PATENT POSITION THE PATIENT SUPINE (IF POSSIBLE) AND POSITION THE PATIENT SUPINE (IF POSSIBLE) AND

ALIGN THE TRANSDUCER WITH THE MID AXILLA ALIGN THE TRANSDUCER WITH THE MID AXILLA (LEVEL WITH THE RIGHT ATRIUM)(LEVEL WITH THE RIGHT ATRIUM)

ZERO THE MONITORZERO THE MONITOR OBSERVE THE CVP TRACEOBSERVE THE CVP TRACE DOCUMENT THE READING AND REPORT ANY DOCUMENT THE READING AND REPORT ANY

CHANGES OR ABNORMALITIESCHANGES OR ABNORMALITIES

THE CVP WAVEFORMTHE CVP WAVEFORM The CVP waveform reflects The CVP waveform reflects

changes in right atrial pressure changes in right atrial pressure during the cardiac cycleduring the cardiac cycle

NORMAL CVP NORMAL CVP MEASUREMENTSMEASUREMENTS

Central venous presure monitoring Central venous presure monitoring should normally show measurements should normally show measurements as follows:as follows:

Mid Axilla: 0 - 8 mmHg (Woodrow 2000)Mid Axilla: 0 - 8 mmHg (Woodrow 2000) An isolated CVP reading is of limited An isolated CVP reading is of limited

value; a trend of readings is much more value; a trend of readings is much more significant and should be viewed in significant and should be viewed in conjuncton with other parameters e.g. conjuncton with other parameters e.g. BP and urine output.BP and urine output.

CENTRAL

VENOUS

PRESSURE

CVP

BLOOD VOLUME

(INCREASED VENOUS RETURN RAISES CVP

CARDIAC COMPETENCE (REDUCED VENTRICULAR FUNCTION RAISES CVP)

INTRATHORACIC AND INTRAPERITONEAL PRESSURE (RAISES CVP)

SYSTEMIC VASCULAR RESISTENCE (INCREASED TONE RAISES CVP)

MANAGEMENT OF A MANAGEMENT OF A PATIENT WITH A CVP LINEPATIENT WITH A CVP LINE

Monitor the patient for signs of Monitor the patient for signs of complicationscomplications

Label CVP lines with drugs/fluids etc. Label CVP lines with drugs/fluids etc. being infused in order to minimise the risk being infused in order to minimise the risk of accidental bolus injectionof accidental bolus injection

If not in use, flush the cannula regularly to If not in use, flush the cannula regularly to help prevent thrombosis. A 500ml bag of help prevent thrombosis. A 500ml bag of 0.9% normal saline should be maintained 0.9% normal saline should be maintained at a pressure of 300mmHg.at a pressure of 300mmHg.

Ensure all connections are secure Ensure all connections are secure to prevent exsanguination, to prevent exsanguination, introduction of infection and air introduction of infection and air emboliemboli

Observe the insertion site Observe the insertion site frequently for signs of infection.frequently for signs of infection.

The length of the indwelling The length of the indwelling catheter should be recorded and catheter should be recorded and regularly monitored.regularly monitored.

CVP lines should be removed when CVP lines should be removed when clinically indicatedclinically indicated

REMOVAL OF CENTRAL LINEREMOVAL OF CENTRAL LINE

THIS IS AN ASEPTIC PROCEDURETHIS IS AN ASEPTIC PROCEDURE THE PATIENT SHOULD BE SUPINE WITH HEAD TILTED THE PATIENT SHOULD BE SUPINE WITH HEAD TILTED

DOWNDOWN ENSURE NO DRUGS ARE ATTACHED AND RUNNING ENSURE NO DRUGS ARE ATTACHED AND RUNNING

VIA THE CENTRAL LINEVIA THE CENTRAL LINE REMOVE DRESSINGREMOVE DRESSING CUT THE STITCHESCUT THE STITCHES SLOWLY REMOVE THE CATHETERSLOWLY REMOVE THE CATHETER IF THERE IS RESISTENCE THEN CALL FOR ASSISTANCEIF THERE IS RESISTENCE THEN CALL FOR ASSISTANCE APPLY DIGITAL PRESSURE WITH GAUZE UNTIL APPLY DIGITAL PRESSURE WITH GAUZE UNTIL

BLEEDING STOPSBLEEDING STOPS DRESS WITH GAUZE AND CLEAR DRESSING EG DRESS WITH GAUZE AND CLEAR DRESSING EG

TEGADERMTEGADERM

ARTERIAL LINESARTERIAL LINES

WHAT IS AN ARTERIAL LINE?WHAT IS AN ARTERIAL LINE?

AN ARTERIAL LINE IS AN ARTERIAL LINE IS A CANNULA A CANNULA USUALLY USUALLY POSITIONED IN A POSITIONED IN A PERIPHERAL ARTERYPERIPHERAL ARTERY

SUCH ASSUCH AS Radial arteryRadial artery brachial arterybrachial artery dorsalis pedis arterydorsalis pedis artery femoral arteryfemoral artery

INDICATIONS FOR USING INDICATIONS FOR USING ARTERIAL LINEARTERIAL LINE

Ease of accessEase of access Continuous monitoring Continuous monitoring

of arterial blood of arterial blood pressurepressure if patient is on if patient is on

intropic drugsintropic drugs if patient is on if patient is on

vasoactive drugvasoactive drug if patient requiresif patient requires

frequent arterial frequent arterial blood samplingblood sampling

COMPLICATIONS ASSOCIATED COMPLICATIONS ASSOCIATED WITH ARTERIAL LINESWITH ARTERIAL LINES

HYPOVOLAEMIAHYPOVOLAEMIA ACCIDENTAL INTR-ARTERIAL ACCIDENTAL INTR-ARTERIAL

INJECTION OF DRUGSINJECTION OF DRUGS LOCAL DAMAGE TO ARTERYLOCAL DAMAGE TO ARTERY

THE ARTERIAL WAVEFORMTHE ARTERIAL WAVEFORM The arterial waveform The arterial waveform

reflects the pressure reflects the pressure generated in the generated in the arteries following arteries following ventricular contraction ventricular contraction and can be described and can be described as having:-as having:- Anacrotic notchAnacrotic notch Peak systolic Peak systolic

pressurepressure Dicrotic notchDicrotic notch Diastolic pressureDiastolic pressure

REMOVAL OF ARTERIAL LINEREMOVAL OF ARTERIAL LINE

THIS IS AN ASEPTIC PROCEDURETHIS IS AN ASEPTIC PROCEDURE REMEMBER UNIVERSAL PRECAUTIONSREMEMBER UNIVERSAL PRECAUTIONS THE PROCEDURE SHOULD BE EXPLAINED TO THE THE PROCEDURE SHOULD BE EXPLAINED TO THE

PATIENTPATIENT TAKE DRESSING OFF LINETAKE DRESSING OFF LINE REMOVE ARTERIAL LINE ENSURING THAT THE REMOVE ARTERIAL LINE ENSURING THAT THE

ENTRY SITE IS COVERED WITH GAUZEENTRY SITE IS COVERED WITH GAUZE APPLY DIGITAL PRESSURE FOR AT LEAST 5 APPLY DIGITAL PRESSURE FOR AT LEAST 5

MINUTES TO ENSURE HAEMOSTASISMINUTES TO ENSURE HAEMOSTASIS DRESS SITE WITH GAUZE AND MICROPOREDRESS SITE WITH GAUZE AND MICROPORE ASSESS THE PERIPHERAL CIRCULATION AS ASSESS THE PERIPHERAL CIRCULATION AS

THROMBOSIS CAN OCCUR AFTER REMOVALTHROMBOSIS CAN OCCUR AFTER REMOVAL

QUESTIONS????QUESTIONS????