central line insertion & pneumothorax · central line insertion & pneumothorax katherine...
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![Page 1: Central Line Insertion & Pneumothorax · Central Line Insertion & Pneumothorax Katherine Freedman RN, BSN, CCRN Villanova University // Crozer Chester Medical Center. 83 y.o. Male](https://reader033.vdocuments.mx/reader033/viewer/2022042807/5f826d1a538f7436bb0fdc32/html5/thumbnails/1.jpg)
Central Line Insertion& Pneumothorax
Katherine Freedman RN, BSN, CCRNVillanova University // Crozer Chester Medical Center
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83 y.o. Male presents for a TAVR
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What is a TAVR you ask?
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TAVR: Transcatheter Aortic Valve ReplacementA minimally invasive approach for implanting an artificial valve inside
a stenotic aortic valve, performed under fluoroscopy.
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TAVR: Too unstable for traditional valve replacement surgery
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History of Presenting Illness● 83 y.o.● Aortic Stenosis● NKDA● Height: 180.3 cm● Weight: 75.3 kg
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Past Medical History● Aortic Valve Stenosis● Cardiomyopathy● CAD● Hyperlipidemia● Anemia● HTN
● CKD● Bladder neoplasm● Diverticulosis● GERD
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Aortic Valve Stenosis● AS causes an increased preload
○ LV Concentric Hypertrophy○ Increased LV diastolic function
■ Increased risk for ischemia● Reliance on atrial “kick”
○ Maintain NSR ● Sensitivity to changes in SVR
○ Decreased perfusion and CO● Sensitivity to volume changes
○ Hypovolemia → decreased preload → decreased CO ● Sensitivity to rate changes
○ Tachycardia → decreased ejection time → decreased myocardial perfusion
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AS VS ARParameter AS AR
LV preload Increased Normal to increased
HR Normal to slow Modest increase
Rhythm SR SR
Contractility Maintain Maintain
SVR Modest increase Decrease
PVR Maintain Maintain
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Medications● Aspirin● Lovastatin● Metoprolol● Keflex● Coenzyme Q● Vitamin B12● Iron
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Labs● K: 4.2● BUN: 24● Cr: 1.1● Glucose: 117● eGFR: >60
● Hgb: 10.9● Hct: 34.3● APTT: 32● PT: 13.4● INR: 1.03
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Diagnostic Studies● 12 Lead EKG, ECHO, Cardiac Cath● 12 Lead EKG shows NSR● “Severe Aortic Stenosis” with an aortic valve area 0.8 cm2
○ Nagelhaut defines severe as <0.5 cm2 and moderate as 0.7-0.9 cm2
● EF 30%● Moderate MR● Trace TR
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The Plan● Preinduction Art Line● Fentanyl, Versed, Etomidate, Vecuronium induction● Intubate with 8.0 Oral ETT● Sevoflurane● Right IJ CVC with PA Catheter● Extubate and transfer to CIUC
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When they told me I would be doing the art line and then intubating
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Post-Induction Picture● HR: 70-80’s● BP: 130s/90s● SPO2: 99%● ETCO: 33-36 mmHg● Vent Settings: VC // VT 550 // RR 10 // PEEP 5 ● Sevo 1.5%
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Then they said I would be getting sterile to place the CVC
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And they told me I would do fine
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What could possibly go wrong?● Infection (5-26%)● Pneumothorax (30%)● Hemothorax● Hematoma (2-26%)● Arterial insertion (4.2-9.3%)● The inexperienced student with 3 “coaches” on the sidelines
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The Setup ● Patient will be fully draped from head to toe● Exposed skin will be prepped with Chlorhexidine
○ The most efficacious antiseptic● Clinician’s hair will be covered and a mask will be worn● Clinician will don sterile gown and gloves
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How it felt when I was donning the sterile gown
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The Position ● Right side IJ CVC insertion● 10-15° Trendelenburg
○ Allows gravity to enhance central venous filling○ Creates a larger target and smaller risk of air embolism
● Head rotated to the left● Physical landmarks● Insert the needle at a 30-40° angle
○ Caudally toward the ipsilateral nipple
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What a view
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Actual footage of me at the head of the bed while sterile
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USE THE ULTRASOUND, KATE.
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Not compressibleCompressible
Transverse View of the Right Neck StructuresMedial Lateral
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The Kit
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The Insertion● Insert the introducer needle at a 30-40° angle
○ Caudally toward the ipsilateral nipple○ Aspirate the whole time
● Remove the syringe and needle from the introducer catheter● Attach the pressure transducing tubing
○ Confirm venous placement○ Remove
● Insert guidewire○ Be cognizant of the distance, never lose visualization of the guidewire
● Remove Introducer catheter● Use scalpel to dilate insertion site● Insert Central venous access device with gentle pressure, do not force it● Aspirate all air and then flush and cap● Suture into place
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Seldinger TechniqueInsertion of a catheter into an artery or vein by inserting narrow bore needle and then advancing a guidewire through the existing catheter, then a larger catheter may be placed over the guidewire.
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How it feels preparing and inserting a PA Catheter for the first time
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PA Catheter Insertion
0-10
15-30/0-8 15-30/5-15
5-15
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PA Catheter Insertion● IJ to SVC● IJ to RA● IJ to RV● IJ to PA● IJ to PCW
● 15 cm
● 35-45 cm● 25-35 cm● 15-25 cm
● 40-50 cm
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Post Insertion Picture● HR: 70-80’s● BP: 130s/90s● SPO2: 99%● ETCO: 30-35 mmHg● CVP 11 // PAP 29/17● Vent Settings: VC // VT 550 // RR 10 // PEEP 5 ● Sevo 1.5%
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About 10 minutes later...
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ETCO2 is 16 mmHg with a dampened waveform
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What do you want to do?
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What do you want to do?● Troubleshoot
○ Manually ventilate○ Check all connections○ Check ETCO2 tubing○ Check water trap○ Auscultate
● Lower MV○ Drop VT to 500 and RR to 8
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ETCO2 is holding steady at 14-16 mmHg, PCO2 28. Everything is connected, vital signs are stable,
the patient is easy to manually ventilate, and had no change in ETCO2 when lowering MV.
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Hypocarbia Causes● Increased Carbon Dioxide Elimination● Decreased Pulmonary Perfusion● Decreased Carbon Dioxide Production● Airway/Equipment Problems
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Hypocarbia Complications● Decreased myocardial oxygen supply● Increased coronary vascular resistance● Increased risk of coronary artery vasospasm● Increased coronary microvascular leakage● Increased myocardial oxygen demand● Decreased cerebral blood flow● Decreased cerebral oxygen delivery
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Differential Diagnosis ● Hyperventilation● Decreased CO● Pulmonary Embolism● Pneumothorax● Esophageal Intubation● Extubation● Deep Anesthetic
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Pneumothorax
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Pneumothorax● Respiratory distress● Hypoxia● Tachypnea● Absent or distant lung sounds● Tachycardia● Pulsus paradoxus ● We did not have a normal presentation
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Pneumothorax● One of the most common complications of CVC insertion
○ Incidence between 1-6.6%○ Represents 30% of all CVC complications
● More likely to occur with○ Emergent situations, large catheters, increased number of
needle passes, SC vs IJ, inexperience
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What went wrong?● Inexperience● Clinician inserting was not the one to drape● Feeling rushed so as not to upset the surgeon● “Through and Through”
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Resolution● Right sided chest tube was placed by the surgeon● The pneumothorax was caught early and did not worsen with
positive pressure ventilation● Serial ABGs● Extubated and transferred to CICU without complication
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References 1. Ayas NT, Norena M, Wong H, Chittock D, Dodek PM. Pneumothorax after insertion of central venous catheters in the intensive care unit: association with month of year and week of month. Quality & Safety in Health Care. 2007;16(4):252-255. doi:10.1136/qshc.2006.021162.
2. Bannon MP, Heller SF, Rivera M. Anatomic considerations for central venous cannulation. Risk Management and Healthcare Policy. 2011;4:27-39. doi:10.2147/RMHP.S10383.
3. Freeman BS, Berger JS. Anesthesiology Core Review. New York, NY: McGraw-Hill; 2014.
4. Kornbau C, Lee KC, Hughes GD, Firstenberg MS. Central line complications. International Journal of Critical Illness and Injury Science. 2015;5(3):170-178. doi:10.4103/2229-5151.164940.
5. Nagelhout JJ, Plaus KL. Nurse Anesthesia. 5th Edition. St. Louis, MO: Elsevier; 2014.
6. Roldan CJ, Paniagua L. Central Venous Catheter Intravascular Malpositioning: Causes, Prevention, Diagnosis, and Correction. Western Journal of Emergency Medicine. 2015;16(5):658-664. doi:10.5811/westjem.2015.7.26248.
7. Tsotsolis N, Tsirgogianni K, Kioumis I, et al. Pneumothorax as a complication of central venous catheter insertion. Annals of Translational Medicine. 2015;3(3):40. doi:10.3978/j.issn.2305-5839.2015.02.11.