Central Venous Central Venous CatheterizationCatheterization

By: Ms. Adnan A. Tander

ICU- Staff Nurse

OBJECTIVESOBJECTIVES Definition Indications/Purpose Prerequisite Nursing Knowledge Relative Contraindications Complications Common Approach for CVC Insertion Patient and Family Education Patient Assessment and Preparation Patient Monitoring and Care CVP Measurement Documentation/Nurse’s Note Basic Materials/Equipments

Definition:

Central Venous Catheter “Central Line”, “CVC”, Central Venous Line, Central Venous Access Catheter – is a catheter placed into a large vein (Internal Jugular, External Jugular, Subclavian, or Femoral vein), passing through a peripheral vein and ending in the thoracic/superior vena cava.

INDICATIONS/PURPOSEINDICATIONS/PURPOSE Central Venous Pressure Monitoring Volume Resuscitation Cardiac Arrest Lack of Peripheral Access Total Parenteral Nutrition Blood Transfusion Blood Sampling (frequent blood draws) Infusion of Concentrated Solutions Placement of Transvenous Pacemaker Cardiac Catheterization, Pulmonary Angiography Hemodialysis

• Decide if the line is really necessary.• Understand and know the normal anatomy and physiology of the cardiovascular system.• Advanced cardiac life support knowledge and skills are needed.• Understand and know the implications, and relative complications of Central Venous Catheter Insertion.• Must have knowledge with the common sites for CVC placement.• Obtain optimal patient positioning and cooperation.• Follow strict sterile protocol• Be familiar with your equipment.• Obtain chest X-ray post line placement and review it.• Understand and know how to measure CVP and its normal values.

BASIC PRINCIPLES ANDPREREQUISITE NURSING KNOWLEDGE

RELATIVE RELATIVE CONTRAINDICATIONSCONTRAINDICATIONS

Bleeding disorders/coagulopathies

(eg. Hemophilia A&B, DIC,

prolonged PT, PTT, INR) Anticoagulation or thrombolytic therapy

(on continuous IV Heparine infusion, oral Warfarin) Combative patients Distorted local anatomy Cellulitis, burns, severe dermatitis at site Vasculitis Presence of pace maker Fever

COMPLICATIONS OF CVC INSERTION

• Pneumothorax • Tension Pneumothorax • Delayed Pneumothorax • Hydrothorax/Hydromediastinum• Hemothorax• Arterial Puncture/Laceration• Bleeding/Hematoma• Cardiac Dysrythmias• Air Embolism• Catheter Malposition• Catheter Embolism

• Pericardial Tamponade• Tracheal Injury • Nerve Injury• Thrombophlebitis• Pulmonary Embolism• Sepsis• Celulitis• Osteomyelitis• Septic Arthritis• Bowel or Bladder Perforation

COMPLICATIONS CLINICALMANIFESTATION

TREATMENT PREVENTION

PNEUMONTHORAX

TENSION PNEUMOTHORAX

DELAYED PNEUMOTHORAX

-Sudden respiratory distress-Chest pain-Hypoxia/cyanosis-Decreased breath sounds-Resonance to percussion

-Most likely to occur in patients on ventilatory support-Respiratory distress-Cyanosis-Venous distension-Hypotension-Decreased cardiac output

-Slow onset of respiratory symptoms-Subcutaneous emphysema-Persistent chest pain or back pain

-Confirmation by chest x-ray-Symptomatic treatment-Small pneumothorax: *bed rest, Oxygen-Peumothorax >25% *chest tube *Cardiopulmonaryardiopulmonary supportsupport -Treatment must be rapid and aggressive-Immediate air aspiration followed by chest tube-Cardiopulmonary support

-Confirmation by chest x-ray-Chest tube-Cardiopulmonary support

-Proper patient preparation-Proper patient positioning-Sedation as necessary-Adequate hydration status

-Proper patient preparation-Proper patient positioning-Sedation as necessary-Adequate hydration-Reduction of PEEP< 5cmH2O at time of venipuncture

-Proper patient preparation-Proper patient positioning-Sedation as needed-Adequate hydrationstatus

COMPLICATIONS CLINICAL

MANIFESTATION TREATMENT PREVENTION

HYDROTHORAX/HYDRO-MEDIASTINUM

HEMOTHORAX

ARTERIAL PUNCTURE/LACERATION

-Dyspnea-Chest pain-Muffled breath sounds-Low-grade fever-High glucose level of chest drainage

-Respiratory distress-Hypovolemic shock-Hematoma in the neck with jugular insertions

-Return of bright red blood in the syringe under high pressure-There is Pulsation-Respiratory distress-Hemorrhagic shock-Bleeding from catheter site-Deviation of trachea with large hematoma in the neck-Hemothorax

-Stop infusion-Confirmation by chest x-ray-Cardiopulmonary support

-Confirmation by chest x-ray-Chest tube-Thoracotomy for arterial repair if indicated

-Application of pressure for 3-5mins following removal of needle-Elevate head of bed-Chest tube as indicated-Thoracotomy for arterial repair if indicated

-Proper patient preparation-Proper patient positioning-Sedation as needed-Adequate hydration status

-Correct coagulopathies before insertion-Adequate hydration status-Avoid multiple pricking

-Correct coagulopathies before insertion-Avoid multiple pricking-Adequate hydration status

COMPLICATIONS CLINICALMANIFESTATION

TREATMENT PREVENTION

BLEEDING/HEMATOMA(VEMOUS/ARTERIAL)

CARDIAC DYSRYTHMIAS

AIR EMBOLISM

-Bleeding from insertion site-Hematoma formation-Tracheal compression-Respiratory distress-Carotid compression

-PVCs, SVTs, Vtach-Premature atrial contractions-Atrial flutter-Sudden cardiovascular collapse

-Tachypnea-Apnea-Tachycardia-Hypotension-Cyanosis-Anxiety-Paresis/stroke-Sudden cardiovascular collapse-Coma-Cardiac arrest

-Application of pressure to the insertion site-Thoracotomy for arterial repair-Tracheostomy for tracheal deviation from hematoma

-Withdarw the guidewire or catheter from the heart-Pharmacologic treatment of persistent arrythmias

-Adequate hydration status-Head-down tilt or Trendelenburg position during catheter insertion

-Correct coagulopathies before insertion-Adequate hydration status-Avoid multiple pricking

-Avoid entry into the heart with guide wire/catheter-Observe cardiac monitor

COMPLICATIONS CLINICAL MANIFESTATION

TREATMENT PREVENTION

CATHETERMALPOSITION

CATHETER EMBOLISM

PERICARDIAL TAMPONADE

-Pain in ear or neck-Swishing sound in ear with infusion-Sharp anterior chest pain-Pain in shoulder blade-Cardiac dysrythmias-No blood return on aspiration-Observation on chest x-ray

-Cardiac dysrythmias-Chest pain-Dyspnea-Hypotension-Tachycardia

-Retrosternal/epigastric pain, pleural effusion-Dyspnea, hypotension-Venous engorgement of face and neck-Restlessness, confusion-Paradoxical pulse-Cardiac arrest

-Position the patient in a high Fowler’s position to allow gravity to correct jugular tip malposition-Repositioning of catheter with guide wire under fluoroscopy or new venipuncture-Catheter removal

-Location of fragment on x-ray-Transvenous retireval of catheter fragment-Thoracotomy if indicated

-Treatment must be rapid and aggressive -Stop infusions-Aspiration through the catheter-Emergency pericardio- centesis-Emergency thoracotomy-Aspiration of air

-Proper patient positioning

-Extreme caution in venipuncture

-Extreme caution in venipuncture

COMPLICATIONS CLINICAL MANIFESTATION

TREATMENT PREVENTION

TRACHEAL INJURY

NERVE INJURY

PULMONARYEMBOLISM

THROMBO-PHLEBITIS

-Subcutaneous emphysema-Pneumomediastinum-Air trapping between the chest wall and the pleura-Respiratory distress with puncture of ETT cuff

-Tingling/numbness in arm or fingers-Shooting pain down the arms-Paralysis

-Chest pain, Dyspnea-Tachycardia, Coughing-Anxiety, Fever

-Redness, tenderness, swelling along the course of the vein-Pain in the upper extremity or shoulder

-Emergency reintubation for punctured ETT cuff-Aspiration of air in mediastinum

-Remove catheter if suspected brachial plexus injury

-Chest x-ray-Lung perfusion scan-Cardiopulmonary support

-Hot compression for 48 to 72 hours-Removal of catheter

-Extreme caution in venipuncture

-Extreme caution in venipuncture

-Avoid catheter exchange in veins with thrombosis

-Strict aseptic technique during catheter insertion-Proper and adequate skin preparation

APPROACH FOR CVC INSERTION APPROACH FOR CVC INSERTION

1. INTERNAL JUGULAR APPROACH Positioning - Right side preferred-lower pleural dome and thoracic duct on left - Trendelenburg position(10-15 degrees)

- Head turned slightly away from the site of venipuncture

2. SUBCLAVIAN APPROACH Positioning- Right side preferred- Supine position, head neutral, arm abducted- Trendelenburg position (10-15 degrees)- Shoulders neutral with mild retraction

3. FEMORAL APPROACHPositioning- Supine/Flat position

Location Advantage Disadvantage

Internal

Jugular

• Bleeding can be recognized

and controlled

• Malposition is rare

• Less risk of pneumothorax

• Risk of carotid artery puncture

• Pneumothorax is possible

Subclavian • Most comfortable for

conscious patient

• Highest risk of bleeding

• Vein is non-compressible/deep vein

• Highest risk of Pneumothorax

Femoral • Easy to find vein

• No risk of Pneumothorax

• Preferred site for

emergencies and CPR

• Fewer bad complications

•Highest risk of infection

• Risk of DVT

• Not good for ambulatory

patients

                                                                                              

Internal Jugular Central Approach

Femoral artery

Femoral nerve

Femoral Vein

NAVEL

Post-Catheter PlacementPost-Catheter Placement

Aspirate blood from each port Flush with saline or sterile water Secure catheter with sutures Cover properly and neatly with sterile dressing

(tega-derm) or Opsite Obtain chest x-ray for IJ and SC lines Measure CVP Documentation/Nurse’s Note

PATIENT AND FAMILY EDUCATION

• Explain the procedure to the patient and family, and reinforce information given. Rationale: Prepares the patient and family and reduces anxiety.

• Explain the required positioning for the procedure and the importance of not moving during the insertion (for conscious patient). Rationale: Encourages cooperation and reduces anxiety.

• Explain the need for sterile technique and that the patient’s face may be covered. Rationale: Decreases patient anxiety and elicits cooperation.

PATIENT ASSESSMENT AND PREPARATION

Patient Assessment

• Assess Vital Signs and pulse Oximetry Rationale: Provides baseline data.

• Assess cardiac and pulmonary status Rationale: Some patients may not tolerate a supine or Trendelenburg position for extended periods.

• Assess coagulophatic status/recent anticoagulant/ thrombolytic therapy Rationale: These patients are more likely to have complications related to bleeding.

Patient Preparation

• Ensure that the patient and family understand the pre- procedural teaching. Answer questions as they arise and reinforce information as needed. Rationale: Evaluates and reinforces understanding of previously taught information.

•Ensure that Informed Consent was obtained Rationale: Protects the rights of the patient and makes a competent decision possible for the patient; however under emergency circumstances, time may not allow for this formed to be signed.

• If needed, performed endotracheal/tracheostomy suctioning on ventilated patients before the procedure. Rationale: Minimize the risk of contamination of the sterile field and the need to interrupt the procedure for suctioning.

Patient MonitoringAnd Care

Rationale Reportable Conditions

1. Monitor the patient’s vital signs and assess level of consciousness before, during, and after the procedure.

Identifies signs and symptoms of complications and allows for immediate interventions.

• Abnormal vital signs • Changes in level of consciousness (if patient is conscious)

2. If the catheter was placed for obtaining CVP measurement, assess the waveform.

Ensures that catheter is in the proper location for monitoring. Allows assessment of a, c and v waves and measurement of pressure.

• Abrupt and sustained changes in pressure• Abnormal waveforms

3. Observe the catheter site for bleeding or hematoma every 15 to 30 minutes for the first 2 hours after insertion.

Post insertion bleeding may occur in a patient with coagulopathies or arterial punctures, multiple attempts at vein access, or with the use of through-the-needle introducer designs for insertion.

• Bleeding or hematoma

4. Assess heart and lung sounds before and after the procedure.

Abnormal heart and lung sounds may indicate cardiac tamponade, pneumothorax, or hemothorax.

• Diminished or muffled heart sounds• Absent or diminished breath sounds unilaterally

5. Monitor for signs and symptoms of complications.

May decrease mortality if recognizedEarly.

• Signs and symptoms of complications

PATIENT MONITORING AND CARE

CENTRAL VENOUS PRESSURE MEASUREMENT

DefinitionThe Central Venous Pressure (CVP) or the Right Atrial Pressure (RAP) - is the pressure measured at the tip of a catheter placed within a central vein or the Right Atrium (RA).

Purpose:• To assess patient’s fluid volume status.• To assess preload of the heart• Provide information about the Right Ventricular function and allows for evaluation of right-sided heart hemodynamics and evaluation of patient response to therapy.

METHODS FOR MEASURING CVP

• Water Manometer Flush System – provide only a numerical value and measure centimeters of water pressure (cm of H2O). Water manometer values will be higher than mercury readings.

• Hemodynamic Monitoring/Mercury Transducer System - allow for analysis of the waveform and measurement of the pressure by mm Hg pressure.

Formula for conversion: cm H2O÷1.36 = mm Hg

Normal CVP value: 2 to 7 mm Hg = 3 to 10 cm H2O

BASIC PRINCIPLES IN MEASURING CVP

• Follow strict standard precautions, wash hands before and after measuring CVP to reduce transmission of microorganism. • Wear gloves (mask and gown for isolated cases).• Put patient on supine/flat position (if no contraindication).• To ensure accuracy of measurement, locate the phlebostatic axis/ mid axilla of the patient and place the zero level of the water manometer at the level of the phlebostatic axis by using carpenter’s level. • Wipe each port with alcohol swab before and after using.• Flush the line with plain NS and check for back-flow/patency before measuring CVP.• Check CVP at the proximal port.• To avoid inconsistency, always check CVP at the same port and same position.

CONDITIONS CAUSING INCREASED CVP

• Elevated vascular volume• Increased cardiac output (hyper dynamic cardiac function)• Depressed cardiac function ( RV infarct, RV failure)• Cardiac tamponade• Constrictive pericarditis• Pulmonary hypertension• Chronic left ventricular failure

CONDITIONS CAUSING DECREASED CVP

• Reduced vascular volume• Decreased mean systemic pressure (eg, late shock states)• Venodilation (drug induced)

DOCUMENTATIONDOCUMENTATION

Patient and Family Education Vital Signs Document the name of procedure and describe what

you did including the preparation of the patient Indication for procedure Insertion site , type and size of catheter and

level/centimeter mark at skin Medications Administered Date and time of procedure

• Type of dressing applied• Initial CVP value• Informed consent• Nursing Interventions• Patient Tolerance• Confirmation of Placement i.e. chest x-ray• Any complications and the interventions taken

NURSE’S NOTES SAMPLE:

11/08/1432 (1000HR) – THE PATIENT HAS NO PERIPHERAL LINE ACCESS AND IN NEED OF INTRAVENOUS ACCESS DUE TO SEVERE SHOCK. SO, UNDER LOCAL ANESTHESIA, A 7 FRENCH, TRIPLE LUMEN CENTRAL VENOUS CATHETER WAS INSERTED BY DR. BASSAM TAHA AT THE RIGHT SUBCLAVIAN AND SUTURED IN PLACE AT LEVEL 15 CM. THE AREA WAS CLEANED AND DRESSING (OPSITE) WAS APPLIED PROPERLY AND NEATLY. CHEST X-RAY WAS TAKEN AND SHOWING THE TIP OF THE CATHETER PROPERLY IN PLACE WITHIN THE SUPERIOR VENA CAVA. INITIAL CVP MEASURED 10 CM H2O. THE PATIENT TOLERATED THE PROCEDURE WITHOUT ANY COMPLICATIONS. VITAL SIGNS ARE STABLE WITH HR 75Bpm, RR 20 CYCLES/MIN, BP 120/80 mm Hg, SPO2 98% ON SIMV VENTILATORY SUPPORT, TPR 37.5 DEGREES CENTIGRADE. PRIOR TO THE PROCEDURE, CONSENT WAS SECURED.

Basic Materials/EquipmentsBasic Materials/Equipments

•Catheter of choice (single/double/triple lumen), size •Face mask, surgical caps, sterile gloves, sterile gowns, drapes•Antiseptic solution/Povidone-iodine scrub, gauze sponges, dressing set/suture set•Syringes(1cc,10cc),Three-way stopcock, 2-0 silk/nylon suture curve•Alcohol, Lidocaine 1%, Heparinized Saline Flush, Transparent dressing/ Tegaderm/Opsite• Sterile IV Set , Plain Normal Saline• Water Manometer • Carpenter’s level

References References Clinical Procedures in Emergency Medicine,

Roberts and Hedges, 4th edition, 2004Clinician’s Pocket Reference, Leonard Gomella,

8th edition, 1997Atlas of Human Anatomy, Frank Netter, 2nd

edition, 1997 AACN Procedure Manual for Critical Care,

Debra J. Lynn-McHale/Karen K.Carlson, 4th Edition

Thank you!