iv central lines ppt

How to start an IVHow to start an IV

Required EquipmentRequired Equipment

IV CatheterIV Catheter IV TubingIV Tubing IV SolutionIV Solution

– TourniquetTourniquet Alcohol or Betadine PreparationAlcohol or Betadine Preparation Dressing, Tape, Band-aidsDressing, Tape, Band-aids GlovesGloves

IV EquipmentIV Equipment

IV Equipment:IV Equipment:

Equipment PreparationEquipment Preparation Remove tubing and IV fluid from Remove tubing and IV fluid from

their protective coveringstheir protective coverings

Equipment PreparationEquipment Preparation

Remove the protective tab from the Remove the protective tab from the spike portspike port

Equipment PreparationEquipment Preparation

Remove the protective cover from Remove the protective cover from the spike (over the inspection bulb) the spike (over the inspection bulb) of the IV tubingof the IV tubing

Assembly of IV EquipmentAssembly of IV Equipment Close the tubing by rotating the Close the tubing by rotating the

thumb lock to the closed positionthumb lock to the closed position

Assembly of IV EquipmentAssembly of IV Equipment

Assemble the IV tubing to Assemble the IV tubing to the IV fluidthe IV fluid– Insert spike into spike portInsert spike into spike port– Puncture seal with the spike Puncture seal with the spike

by using a twisting, pushing by using a twisting, pushing motion until spike is fully motion until spike is fully insertedinserted

Flushing the IV TubingFlushing the IV Tubing

Flush the line with the IV Flush the line with the IV fluidfluid– With the spike fully inserted With the spike fully inserted

squeeze the drip chamber squeeze the drip chamber between the index finger between the index finger and thumb and immediately and thumb and immediately release. The chamber will release. The chamber will fill with the IV fluidfill with the IV fluid

– Release the line clamp by Release the line clamp by rotating the thumb lock to rotating the thumb lock to the fully opened position. the fully opened position.

Flushing the IV TubingFlushing the IV Tubing

– Raise the IV fluid bag to allow for Raise the IV fluid bag to allow for gravity flowgravity flow

– Allow the IV fluid to fill the line Allow the IV fluid to fill the line completely, eliminating any air within completely, eliminating any air within the linethe line

– Once the tubing is completely filled, Once the tubing is completely filled, clamp the line again by rotating the clamp the line again by rotating the thumb clamp to the closed positionthumb clamp to the closed position

– You are now ready to select an IV siteYou are now ready to select an IV site

Sight SelectionSight Selection HandHand ForearmForearm Antecubital Fossa Antecubital Fossa

(Elbow)***(Elbow)***– Usually easiest and most Usually easiest and most

accessibleaccessible Upper ArmUpper Arm Foot & Lower LegFoot & Lower Leg

– Least favorable, use as last Least favorable, use as last resortresort

Sight SelectionSight Selection

HandHand– Posterior (back of hand) may not Posterior (back of hand) may not

accept large bore IV catheter or allow accept large bore IV catheter or allow rapid volume infusionrapid volume infusion

ForearmForearm– Sometimes difficult to locate veinSometimes difficult to locate vein– Good for rapid infusion of fluids and Good for rapid infusion of fluids and

blood products as well as IV blood products as well as IV medicationsmedications

Arm VeinsArm Veins


Antecubital FossaAntecubital Fossa– Large vesselsLarge vessels– Most accessibleMost accessible– Allows for rapid infusionAllows for rapid infusion– Accepts large bore IV catheterAccepts large bore IV catheter

Disadvantage Disadvantage – Elbow must remain straight to allow Elbow must remain straight to allow

for infusionfor infusion


Upper armUpper arm– Usually very large vesselUsually very large vessel– Sometimes difficult to accessSometimes difficult to access– Straight long vessel (no bends to Straight long vessel (no bends to

occlude catheter)occlude catheter)


Foot and Upper legFoot and Upper leg– Used as a last resortUsed as a last resort– Usually more painful to patientUsually more painful to patient– Furthest form the heartFurthest form the heart– Difficult to manageDifficult to manage

Now you now are ready to attempt Now you now are ready to attempt an IVan IV

Sight PreparationSight Preparation

Identify veinIdentify vein Clean 3 times with alcoholClean 3 times with alcohol Apply tourniquet above veinApply tourniquet above vein Wear glovesWear gloves

Gloves are not worn during demonstration to allow better Gloves are not worn during demonstration to allow better visualization of techniquesvisualization of techniques

Sight PreparationSight Preparation

Place the tourniquet above the Place the tourniquet above the desired IV sitedesired IV site– Should be snug to reduce venous flowShould be snug to reduce venous flow– Makes for easier vein identificationMakes for easier vein identification

Identify veinIdentify vein– Determine the most appropriate veinDetermine the most appropriate vein– Choose the site where the IV is to be Choose the site where the IV is to be

insertedinserted

Sight PreparationSight Preparation Alcohol swabAlcohol swab

– Cleanse the area with an alcohol Cleanse the area with an alcohol swab three times if ableswab three times if able

– Allow area to air dry or wipe Allow area to air dry or wipe excess awayexcess away

Prepare to insert the IVPrepare to insert the IV

IV InsertionIV Insertion Remove the Catheter from the Remove the Catheter from the

packagepackage Remove the protective covering Remove the protective covering

from the Catheterfrom the Catheter

IV InsertionIV Insertion Place the hub of the catheter Place the hub of the catheter

between the thumb and index between the thumb and index finger of one handfinger of one hand

IV InsertionIV Insertion With the other hand grasp the arm lightlyWith the other hand grasp the arm lightly Place the thumb over and below the vein Place the thumb over and below the vein

that you intend to puncture that you intend to puncture

IV InsertionIV Insertion Apply traction to the skin and vein to make Apply traction to the skin and vein to make

those areas taughtthose areas taught Assure the bevel is in the upward positionAssure the bevel is in the upward position Place the needle at the site at a 30Place the needle at the site at a 30°° angle angle

IV InsertionIV Insertion Pierce the skin with the needlePierce the skin with the needle Continue with a forward motion forcing the Continue with a forward motion forcing the

needle into the vein, you should feel a “popping” needle into the vein, you should feel a “popping” sensation, at this point stop momentarily sensation, at this point stop momentarily

IV InsertionIV Insertion Check the hub for a blood returnCheck the hub for a blood return

IV InsertionIV Insertion

You may have to withdrawal the You may have to withdrawal the catheter partially and reattempt catheter partially and reattempt

With blood in the hub, release the With blood in the hub, release the arm with the hand holding tractionarm with the hand holding traction

Advancing IV CatheterAdvancing IV Catheter

While maintaining the While maintaining the grasp to the catheter grasp to the catheter with one hand, hold with one hand, hold the colored portion of the colored portion of the catheter with the the catheter with the index finger and index finger and thumbthumb

Advancing IV CatheterAdvancing IV Catheter Separate the two pieces by slowly advancing Separate the two pieces by slowly advancing

the catheter into the veinthe catheter into the vein Slowly withdraw the needle portion and discard Slowly withdraw the needle portion and discard

it in a “sharp box”it in a “sharp box”

Attaching IV tubingAttaching IV tubing

Place thumb over Place thumb over the end of the the end of the catheter in the catheter in the vein and apply vein and apply pressure to stop pressure to stop blood flow out of blood flow out of the catheterthe catheter

Attaching IV tubingAttaching IV tubing

Remove the Remove the protective cap protective cap from the end of from the end of the IV tubing and the IV tubing and insert the tubing insert the tubing end into the hub end into the hub of the catheterof the catheter

Release TourniquetRelease Tourniquet

Adjust Drip RateAdjust Drip Rate

Apply Tape Securely Apply Tape Securely Around HubAround Hub


Securing the IV Securing the IV is very is very important. You important. You do not want to do not want to have to restart an have to restart an IV IV


Apply a 4 inch Apply a 4 inch strip of tape to strip of tape to the underside of the underside of the catheter hub the catheter hub

Make a chevron Make a chevron and attach it to and attach it to the skin adjacent the skin adjacent to the insertion to the insertion pointpoint


Place tape across Place tape across the top of the the top of the bulb on the bulb on the tubing to secure tubing to secure the tubing to the the tubing to the IV hub and the IV hub and the armarm


Loop the Loop the tubing and tape tubing and tape it into position it into position on the arm. on the arm. This helps to This helps to prevent prevent inadvertent inadvertent dislodgment of dislodgment of the IVthe IV

Dress the insertion site with a Dress the insertion site with a Band-Aid or gauze dressingBand-Aid or gauze dressing

Calculating “Rate”Calculating “Rate” Open the line by using the Open the line by using the

thumb line lock thumb line lock Volume depletion and Volume depletion and

heat casualty require more heat casualty require more rapid infusion (“wide rapid infusion (“wide open”)open”)

Head injury and heart Head injury and heart conditions require less conditions require less aggressive fluid aggressive fluid resuscitation (very slow; 1 resuscitation (very slow; 1 drop every 3 or 4 drop every 3 or 4 seconds)seconds)

Changing the BagChanging the Bag Situations arise when a bag will have to Situations arise when a bag will have to

be changed be changed – Follow the steps when first spiking the bag. Follow the steps when first spiking the bag.

– Remove the protective tab from the new bag Remove the protective tab from the new bag of fluid. of fluid.

– Remove the spiked end of the tubing from Remove the spiked end of the tubing from the expended bag. the expended bag.

– Insert the spike into the port. Insert the spike into the port.

– Squeeze and release the inspection bulb, Squeeze and release the inspection bulb, allow to fill and hang the fluid.allow to fill and hang the fluid.

New tubing is not required New tubing is not required

Basic Intravenous TherapyBasic Intravenous Therapy

90-95% of patients in the 90-95% of patients in the

hospital receive some type hospital receive some type

of intravenous therapy. of intravenous therapy.

This presentation will enhance This presentation will enhance your knowledge of how to care your knowledge of how to care

for them.for them.

Veins are unlike arteries in that Veins are unlike arteries in that they are 1)superficial, 2) display they are 1)superficial, 2) display dark red blood at skin surface and dark red blood at skin surface and 3) have no pulsation 3) have no pulsation

Vein AnatomyVein Anatomy

- - Tunica AdventitiaTunica Adventitia - Tunica Media- Tunica Media - Tunica Intima- Tunica Intima - Valves- Valves

Vein Anatomy and PhysiologyVein Anatomy and Physiology

Tunica AdventitiaTunica Adventitiathe outer layer of the vesselthe outer layer of the vessel

Connective tissueConnective tissue

Contains the arteries Contains the arteries and veins supplying and veins supplying blood to vessel wallblood to vessel wall

Tunica MediaTunica Mediathe middle layer of the vesselthe middle layer of the vessel

Contains nerve endings Contains nerve endings and muscle fibersand muscle fibers

The vasoconstrictive The vasoconstrictive response occurs at this response occurs at this layerlayer

Tunica IntimaTunica Intimathe inner layer of the vesselthe inner layer of the vessel

One layer of endothelialsOne layer of endothelials

No nerve endingsNo nerve endings

Surface for platelet Surface for platelet aggregation aggregation

w/trauma and recognition of w/trauma and recognition of

foreign object at this levelforeign object at this level

PHLEBITIS begins herePHLEBITIS begins here

ValvesValvespresent in MOST veinspresent in MOST veins

Prevent backflow and Prevent backflow and pooling pooling

More in lower extremities More in lower extremities and longer vesselsand longer vessels

Vein dilates at valve Vein dilates at valve attachmentattachment

Veins of the Upper ExtremitiesVeins of the Upper Extremities

Digital VesselsDigital Vessels

-Along lateral aspects fingers, infiltrate easily, painful, difficult to immobilize and should be your LAST RESORT

Metacarpal VesselsMetacarpal Vessels

-Located between joints and metacarpal bones (act as natural splint)

-Formed by union of digital veins

-Geriatric patients often lack enough connective / adipose tissue and skin turgor to use this area successfully

Digital


Cephalic (Intern’s Vein)Cephalic (Intern’s Vein) -Starts at radial aspect of wrist

-Access anywhere along entire length (BEWARE of radial artery/nerve)

Medial Cephalic (“On ramp” to Medial Cephalic (“On ramp” to Cephalic Vein)Cephalic Vein)

-Joins the Cephalic below the elbow bend

-Accepts larger gauge catheters, but may be a difficult angle to hit and maintain


BasilicBasilic

- Originates from the ulner side of the metacarpal veins and runs along the medial aspect of the arm. It is often overlooked becauses of its location on the “back” of the arm, but flexing the elbow/bending the arm brings this vein into view

Medial BasilicMedial Basilic

- Empties into the Basilic vein running parallel to tendons, so it is not always well defined. Accepts larger gauge catheters.

- BEWARE of Brachial Artery/Nerve

Purposes of IV TherapyPurposes of IV Therapy To provide parenteral nutrition To provide avenue for dialysis/apheresis To transfuse blood products To provide avenue for hemodynamic monitoring To provide avenue for diagnostic testing To administer fluids and medications with the ability to rapidly/accurately change

blood concentration levels by either continuous, intermittent or IV push method.

Types of Peripheral Venous Access DevicesTypes of Peripheral Venous Access Devices

•Butterfly (winged) or Scalp vein needles (SVN) – not recommended for non compliant patient as it can easily penetrate the vein wall causing extravasation. We use these frequently for phlebotomy

•Safety Over the needle catheters (ONC)

- PROTECTIV ® -ACUVANCE ®

Starting a Peripheral IVStarting a Peripheral IV Finding a vein can be challengingFinding a vein can be challenging

- Go by “feel”, not by sight. Good veins are bouncy to the touch, but are not always visible.

- Use warm compresses and allow the arm to hang dependently to fill veins.

- A BP cuff inflated to 10mmHg below the known systolic pressure creates the perfect tourniquet. Arterial flow continues with maximum venous constriction.

- If the patient is NOT allergic to latex, using a latex tourniquet may provide better venous congestion

- Avoid areas of joint flexion

- Start distally and use the shortest length/smallest gauge access device that will properly administer the prescribed therapy

(BE AWARE: Blood flow in the lower forearm and hand is 95ml/min)

IV Start Pain ManagementIV Start Pain Management

One of the most frequent contributors to patient dissatisfaction is painful One of the most frequent contributors to patient dissatisfaction is painful phlebotomy and IV startsphlebotomy and IV starts

• Use 25-27g insulin syringe to create a wheal similar to a TB skin test on top of or just to side of vein with 0.1 -0.2 ml normal saline or 1% xylocaine without epinephrine

• Topical anesthesia cream (ie EMLA) may be applied to children>37 weeks gestation 1 hr. prior to stick. It might be a good idea to anesthetize a couple of sites

• Have the patient close their fist (NO PUMPING) prior to stick

• Make sure the skin surface cleansing agent (alcohol/chlorhexidine) is dry prior to stick. Drawing this into the vein may stimulate the vasoconstrictive action of the tunica media layer

Flushing Peripheral IV’sFlushing Peripheral IV’sUse prefilled saline and heparin flush syringes located in PYXIS

Heparin flush concentrations available:

-100u/ml (5ml in a 10ml syringe)

-10u/ml (2ml in a 3ml syringe)Flushing intervals and amounts

- Peds: q 6hrs.

<22ga 1ml 0.9%NS followed by 1ml heparinized (10units/ml) saline

- Adults: q 8hrs w/1ml. 0.9%NS [3ml heparinized saline for OB]

Dressing/Bag ChangesDressing/Bag Changes

TSM q 7 d

Changing dressings1 2 3 4 5 6 7

Gauze q 2 d

Changing Sites

1 2 3

normally every 3d

4 5 6 7

Every 7 d c MD order

Changing bags and tubing

1 2 3

normally every 3d

24 hrs

I f respiked or meds added outside pharmacy

Physician orders are required if a peripheral catheter is left in the same site for more than 3 days.

It is best to have the pharmacy add medications to the infusion bags under laminare flow to reduce contamination

Central Venous CathetersCentral Venous CathetersPercutaneousPercutaneous TunneledTunneled PICC’sPICC’s Implanted PortsImplanted Ports DialysisDialysis

InsertionInsertion MD @ bedside w/x-ray

confirmation

MD in OR under fluoroscopy

MD/trained RN @bedside w/x-ray

confirmation

MD in OR under fluoroscopy MD in OR under fluoroscopy

LocationLocation Visible externally.

Enters subclavian, ext.

juglar,or int. juglar vein near clavicular area

Visible ext. usually midway bet. clavicle and

nipple. Tunneled under skin &

threaded through subclavian or IJ

Visible externally around antecubital fossa, upper arm or

neck

Completely internal. Titanium or plastc port is implanted in a

surgically created pocket and catheter is threaded into

subclavian or int. juglar vein. Access is through skin into self sealing port using special non

coring needle

Visible externally. Arm

or leg placement

Material/Material/CostCost

Polyurethane$200-$400

Silicone$3500-$5000

Silicone / polyurethane$350-$500

Silicone catheter. Port is titanium or plastic w/self sealing diaphragm

$3500-$5000

Various materials

LumenLumen 2-3 2-3 1-2 1-2 2-3

SuturedSutured Yes/entire life Yes, until internal Dacron cuff

healed

No Yes Yes

DurationDuration Short term 4-10 days

Long term Long term Long term Mid term

FlushesFlushes 5-10ml NaCl after use and

daily

5-10ml NaCl after use and daily

5-10ml NaCl after use and daily

10ml NaCl followed by 4.5ml heparinized saline (adults-

100units/ml; peds-10units/ml) after ea. use or monthly if not accessed

Done ONLY by IV team or dialysis

nurses

Brands/Brands/

NamesNamesArrow Howe, Triple Lumen, Subclavian, IJ

Hickman, Broviac PICC, PIC, EDPC, Arrow Howe, Gesco, PASV

Bard, Accces Port-A-Cath Bard, Tesio, Vescath, Quinton

DiscontinueDiscontinue MD or speically trained RN @

bedside

MD in OR Specially trained RN @ bedside

MD in OR MD in OR

Central Venous Catheter Central Venous Catheter SitesSites

PICC (Peripherally inserted Central Catheter)

Percutaneous(Subclavian)

Percutaneous (IJ-Int. Jugular)

Tunnelled (Hickman)

Implanted Port (single or double

lumen)

CVC Care/MaintenanceCVC Care/Maintenance

Flush after each access or daily for catheters>21ga, q 6 hrs <21 ga

-adults: 10ml saline

- peds/neonates: 5ml saline (preservative free for infants <1yr)

Transparent dressing change q 7 days & prn

Percutaneous Tunneled

PICC

CVC Care/MaintenanceCVC Care/Maintenance

Implanted Port

Flush after each use and weekly while accessed; monthly when not acessed

- 10ml saline (preservative free for pts. <1yr)

- followed by 4.5ml-5ml heparinized saline 100units/ml for adults

10units/ml for peds

Transparent dressing/ access needle change q 7days

Site CareSite CareMonitor and document

site condition:

• Hourly for peds

•Q 2 hr for adult

* Indicates complication:

•Infiltration

•Phlebitis

•Thrombosis

•Cellulitis

•Septicemia

Infiltration/ExtravasationInfiltration/Extravasation

The most common cause is damage to the wall during insertion or angle of placement.

STOP INFUSION and treat as indicated by Pharmacy, Medication package insert or drug reference book.

Notify MD and document

Phlebitis/ThrombophlebitisPhlebitis/Thrombophlebitis

Chemical

- Infusate chemically erodes internal layers. Warm compresses may help while the infusate is stopped/changed. Anti-inflammatory and analgesic medications are often used no matter what the cause Mechanical

- Caused by irritation to internal lumen of vein during insertion of vascular access device and usually appears shortly after insertion. The device may need to be removed and warm compresses applied

Bacterial

- Caused by introduction of bacteria into the vein. Remove the device immediately and treat w/antibiotics. The arm will be painful, red and warm; edema may accompany

CellulitisCellulitis

Inflammation of loose connective tissue around insertion site.

- Caused by poor insertion technique

- Red swollen area spreads from insertion site outwardly in a diffuse circular pattern

- Treated w/antibiotics

Septicemia/Pulmonary Edema/Septicemia/Pulmonary Edema/EmbolismEmbolism

Septicemia

- Severe infection that occurs to a system or entire body

- Most often caused by poor insertion technique or poor site care

- Discontinue device immediately, culture and treat appropriately Pulmonary edema- caused by rapid infusion

Pulmonary embolism - Caused by any free floating substances that require thrombolytic therapy for several months. Increased risk w/lower ext.

Air embolism- caused by air injected into IV system. Keep insertion site below level of heart

Vascular access device will not flush/can’t draw blood

- Evaluate for kink in tubing or catheter tip against vein wall.

Vascular access device (VAD) leaking when flushed

- Verify that hub access cap is connected correctly

Patient complains of pain while VAD being flushed

- Assess for infiltration

VAD broken- PICC’s may be repaired. All other devices must be replaced

Call IV therapy team member for any concerns or questions.

TroubleshootingTroubleshooting

Policy notesPolicy notesKVO rate:

Adults - 10 ml/hrPediatrics - 2-3 ml/hrNeonates - 0.5-1 ml/hr

Only until rate order received

Verification required for:

•Insulin

•Heparin

•Potassium

•Digoxin

•Chemotherapy

LPN’s cannot push IV medications

RN’s and LPN’s can start peripheral IV’s after initial training and observation by preceptor

LPN’s CANNOT infuse blood products or high risk IV medications.

IV Medication AdministrationIV Medication Administration

Many medications require patient monitoring that cannot be done on units where the nurse/patient ratios are greater than 1:2

A patient can be moved to a unit where the ratio is appropriate for invasive/frequent monitoring or another nurse can be brought to care for the patient during the med administration

All Medications Cannot Be Administered on All Units

General Care Units:Can give meds requiring only basic physical assessment data

Stepdown Units:Can give meds that require more invasive or frequent monitoring than is available on general care units

Intensive Care Units:Can give meds that require more invasive or frequent monitoring than is available on the Stepdown units.

VANDERBILT URL LINK FOR IV MEDICATIONS:

www.mc.vanderbilt.edu/pharmacy/ivroom/IVMedAdm061003.pdf

http://www.mc.vanderbilt.edu/pharmacy/ivroom/IVMedAdm061003.pdf

IV Medication IV Medication AdministrationAdministration

Sample page from the Pharmacy med administration web site

See “APPROVED FOR” section. You will find if the medication can be administered on your unit.

Infusion Nurses Society (INS)Infusion Nurses Society (INS)

• Professional Organization that sets the standards of Professional Organization that sets the standards of care for clinicians practicing in the field of infusion care for clinicians practicing in the field of infusion therapy.therapy.

• Standards set by INS are reflected in our policies and Standards set by INS are reflected in our policies and procedures related to infusion therapy for health care procedures related to infusion therapy for health care providers.providers.

• In a court of law, the standards set by the INS are In a court of law, the standards set by the INS are used to assess the infusion clinician’s performance. used to assess the infusion clinician’s performance.

www.ins1.org

CENTRAL LINES CENTRAL LINES AND AND ARTERIAL LINESARTERIAL LINES

LEARNING OUTCOMESLEARNING OUTCOMESTHE STUDENT SHOULD BE THE STUDENT SHOULD BE ABLE TO:-ABLE 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 ASSOCIATED DISCUSS THE COMPLICATIONS ASSOCIATED WITH CENTRAL LINES AND ARTERIAL LINESWITH CENTRAL LINES AND ARTERIAL 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 access provides venous access via the superior vena via the superior vena cava or right atriumcava or right atrium

COMMON CENTRAL LINE COMMON CENTRAL LINE INSERTION SITESINSERTION SITES

Right internal Right internal jugularjugular

left internal left internal jugularjugular

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 veins (basilic vein is the best) in the is the best) in the arm and is arm and is advanced into the advanced into the central veinscentral veins

TYPES OF CENTRAL LINETYPES OF CENTRAL LINE

SINGLE LUMENSINGLE LUMEN TRIPLE LUMENTRIPLE LUMEN QUADRUPLE LUMENQUADRUPLE LUMEN 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 Malposition of

the catheterthe catheter haematomahaematoma arterial puncturearterial puncture pneumothoraxpneumothorax haemorrhagehaemorrhage sepsissepsis air emboliair emboli

Catheter Catheter embolismembolism

ThrombosisThrombosis HaemothoraxHaemothorax Cardiac Cardiac

tamponadetamponade Cardiac Cardiac

arrhythmiasarrhythmias

CENTRAL CENTRAL VENOUS VENOUS PRESSUREPRESSURE

WHAT IS CENTRAL WHAT IS CENTRAL VENOUS PRESSUREVENOUS PRESSURE

IS THE PRESSURE WITHIN THE IS THE PRESSURE WITHIN THE SUPERIOR VENA CAVA OR SUPERIOR VENA CAVA OR THE RIGHT ATRIUMTHE RIGHT ATRIUM

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

TO SERVE AS A GUIDE TO TO SERVE AS A GUIDE TO FLUID BALANCE IN FLUID BALANCE IN CRITICALLY ILL PATIENTSCRITICALLY ILL PATIENTS

TO ESTIMATE THE TO ESTIMATE THE CIRCULATING BLOOD CIRCULATING BLOOD VOLUMEVOLUME

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, CIRCULATING BLOOD VOLUME, VASCULAR TONE AND THE PATIENT’S VASCULAR TONE AND THE PATIENT’S RESPONSE TO TREATMENTRESPONSE TO TREATMENT

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

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

PROCEDURE FOR CVP PROCEDURE FOR CVP MEASUREMENT USING A MEASUREMENT USING A TRANSDUCERTRANSDUCER

EXPLAIN THE PROCEDURE TO THE EXPLAIN THE PROCEDURE TO THE PATIENTPATIENT

ENSURE THE LINE IS PATENTENSURE THE LINE IS PATENT POSITION THE PATIENT SUPINE (IF POSITION THE PATIENT SUPINE (IF

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

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

ANY CHANGES OR ABNORMALITIESANY CHANGES OR ABNORMALITIES

THE CVP WAVEFORMTHE CVP WAVEFORM The CVP waveform reflects changes in The CVP waveform reflects changes in

right atrial pressure during the cardiac cycleright atrial pressure during the cardiac cycle

NORMAL CVP NORMAL CVP MEASUREMENTSMEASUREMENTS

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

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

trend of readings is much more significant and trend of readings is much more significant and should be viewed in conjuncton with other should be viewed in conjuncton with other parameters e.g. BP and urine output.parameters e.g. 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 PATIENT WITH A CVP LINELINE 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 being infused in order to minimise the risk of accidental bolus injectionrisk of accidental bolus injection

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

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

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

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

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

REMOVAL OF CENTRAL REMOVAL OF CENTRAL LINELINE

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

HEAD TILTED DOWNHEAD TILTED DOWN ENSURE NO DRUGS ARE ATTACHED AND ENSURE NO DRUGS ARE ATTACHED AND

RUNNING VIA THE CENTRAL LINERUNNING VIA 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 IF THERE IS RESISTENCE THEN CALL FOR

ASSISTANCEASSISTANCE APPLY DIGITAL PRESSURE WITH GAUZE APPLY DIGITAL PRESSURE WITH GAUZE

UNTIL BLEEDING STOPSUNTIL BLEEDING STOPS DRESS WITH GAUZE AND CLEAR DRESSING DRESS WITH GAUZE AND CLEAR DRESSING

EG TEGADERMEG TEGADERM

ARTERIAL ARTERIAL LINESLINES

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 of Continuous monitoring of

arterial blood pressurearterial blood pressure– if patient is on intropic if patient is on intropic

drugsdrugs– if patient is on if patient is on

vasoactive drugvasoactive drug– if patient requiresif patient requires

frequent arterial blood frequent arterial blood samplingsampling

COMPLICATIONS COMPLICATIONS ASSOCIATED WITH ASSOCIATED WITH ARTERIAL LINESARTERIAL 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 arteries generated in the arteries following ventricular following ventricular contraction and can be contraction and can be described as having:-described as having:-– Anacrotic notchAnacrotic notch

– Peak systolic pressurePeak systolic pressure

– Dicrotic notchDicrotic notch

– Diastolic pressureDiastolic pressure

REMOVAL OF ARTERIAL REMOVAL OF ARTERIAL LINELINE

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

TO THE PATIENTTO THE PATIENT TAKE DRESSING OFF LINETAKE DRESSING OFF LINE REMOVE ARTERIAL LINE ENSURING THAT REMOVE ARTERIAL LINE ENSURING THAT

THE ENTRY SITE IS COVERED WITH GAUZETHE ENTRY 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 THROMBOSIS CAN OCCUR AFTER REMOVALREMOVAL

QUESTIONS????QUESTIONS????

iv central lines ppt

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