CENTRAL LINES CENTRAL LINES AND AND

ARTERIAL LINESARTERIAL LINES

Adult ll Clinical Course Adult ll Clinical Course

LEARNING OUTCOMESLEARNING OUTCOMESTHE STUDENT SHOULD BE ABLE TOTHE STUDENT SHOULD BE ABLE TO-:-:

Identify a central line and arterial line .Identify a central line and arterial line .Discuss the indication for central line and Discuss the indication for central line and

arterial line.arterial line.Know how to measure CVP .Know how to measure CVP .Discuss the complications associated withDiscuss the complications associated with

central lines and arterial linescentral lines and arterial lines. . Articulate the management of a patient Articulate the management of a patient

with a central line and arterial linewith a central line and arterial 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 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 Tripple lumen.Tripple lumen.

CENTRAL LINESCENTRAL LINES

Indications for CVP lines areIndications for CVP lines are-:-: Rapid administration of fluids and blood

products in patients with any form of shock

Parenteral feeding Parenteral feeding electrolytes or hypertonic solutions.

measurement of central venous pressuremeasurement of central venous pressure Lack of accessible peripheral veins administration of irritant drugsadministration of irritant drugs

ProcedureProcedure

Position the patient as needed using pillows or rolled towels, or place the patient in the Trendelenberg position; this prevents air from being passively drawn into the venous system during the negative intrathoracic pressure generated by inspiration

Potential complications

Haemorrhagefrom the catheter site -if it becomes disconnected from the infusion. Patients who have coagulation problems such as those on warfarinor those will clotting disorders are at risk.

Catheterocclusion, by a blood clot or kinked tube -regular flushing of the CVC line and a well secured dressing should help to avoid this.

Potential complications

Infection-redness, pain, swelling around the catheter insertion site may all indicate infection. Careful asepsis is needed when touching a CVC site. Swabs for MC&S should be taken if infection is suspected.

Air embolus-if the infusion or monitoring lines become disconnected there is a risk that air can enter the venous system. All lines and connections should be checked at the start of every shift to minimisethe risk of this occurring.

Potential complications

Catheter displacement-if the CVC moves into the chambers of the heart then cardiac arrhythmias may be noted, and should be reported. If the CVC is no longer in the correct position, CVP readings and medication administration will be affected.

CENTRAL VENOUS CENTRAL VENOUS PRESSUREPRESSURE

What is CVPWhat is CVP

Central venous pressureCentral venous pressure (CVP) (CVP) (also known as: right atrial pressure; (also known as: right atrial pressure; RAP) describes the pressure of blood RAP) describes the pressure of blood in the thoracic in the thoracic vena cavavena cava, near the , near the right atriumright atrium of the heart. CVP reflects of the heart. CVP reflects the amount of blood returning to the the amount of blood returning to the heart and the ability of the heart to heart and the ability of the heart to pump the blood into the arterial pump the blood into the arterial system. system.

CVP Readings are usedCVP Readings are used-: -:

To serve as a guide to fluid balance in To serve as a guide to fluid balance in critically ill patients .critically ill patients .

To estimate the circulating blood To estimate the circulating blood volume. volume.

To assist in monitoring circulatory failureTo assist in monitoring circulatory failureThe normal range for CVP is 5-10cm H2O

(2-6mmHg) when taken from the mid-axillary line at the fourth intercostalspace.

Central Venous Pressure Central Venous Pressure MonitoringMonitoring

This is a helpful tool in the assessment of This is a helpful tool in the assessment of cardiac function , circulating blood volume , cardiac function , circulating blood volume , vascular tone and the patient’s response to vascular tone and the patient’s response to treatment.treatment.

However , CVP should not be interrupted Solely However , CVP should not be interrupted Solely but in conjunction with other systemic but in conjunction with other systemic measurements , as isolated CVP measurements measurements , as isolated CVP measurements can be misleading .can be misleading .

CVP measurement should be viewed in conjunction with other observations such as pulse, blood pressure and respiratory rate and the patients response to treatment.

Methods of Central Venous Methods of Central Venous Pressure MonitoringPressure Monitoring

There are two methods of CVP There are two methods of CVP monitoringmonitoringmanometer systemmanometer system:: enables enables

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

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

How to measure CVPHow to measure CVP? ?

Using a manometer

1. Explain the procedure to the patient to gain informed consent.

2. If IV fluid is not running, ensure that the CVC is patent by flushing the catheter.

3. Place the patient flat in a supine position if possible.

Alternatively, measurements can

be taken with the patient in a semi-recumbent position. The position should remain the

same for each measurement taken

to ensure an accurate

comparable result.

Line up the manometer arm with the phlebostatic axis ensuring that the bubble is between the two lines of the spirit level.

Move the manometer scale up and down to allow the bubble to be aligned with zero on the scale. This is referred to as 'zeroing the manometer'.

Turn the three-way tap off to the

patient and open to the manometer.

Open the IV fluid bag and slowly fill the manometer to a level higher than the expected CVP

Monitoring with transducersMonitoring with transducers

Transducers enable the pressure readings Transducers enable the pressure readings from invasive monitoring to be displayed on from invasive monitoring to be displayed on a monitor.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 continuous pressure of 300mmHg thus facilitating a continuous flush of thus facilitating a continuous flush of 3mls/hr3mls/hr

Procedure for CVP measurement using a Procedure for CVP measurement using a transducertransducer

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

Priming the system The transducer set must becarefully primed using a 500ml bag of 0.9% sodium chloride.

Priming purges the air from the tubingsystem. After priming, all stopcocks/taps should be closed to air and all connections checked

and tightened (McGhee and Bridges 2002).

Once the system has been primed, the pressure primed, the pressure bag should be inflated to

300mmHg for adult patients. This provides a constant flush through the device of approximately 3ml per hour and also provides the pressure needed to manually activate the in-line flush device

Levelling The transducer must be level with the patient’s right atrium.

With the patient in the supine position, the position of the patient’s

right atrium is estimated using external landmarks on the patient’s thorax.

Zeroing This is a bedside quality control test to ensure that the equipment is calibrated correctly.

To zero the transducer, the three-way stopcock positioned immediately above the transducer

should be switched off to the patient and opened to the

atmosphere. The stopcock is an interface where the fluid

meets the atmospheric air pressure. Providing the

monitor recognises atmospheric air pressure as zero

Turn the tap off to the patient and open to the air by removing the cap from the three-way port opening the system to the atmosphere.

Press the zero button on the monitor and wait while calibration occurs.

When 'zeroed' is displayed on the monitor, replace

the cap on the three-way tap and turn the tap on to

the patient.

Observe the CVP trace on the monitor.

The waveform undulates as the

right atrium contracts and

relaxes, emptying and filling with

blood. (light blue in this image)

THE CVP WAVEFORMTHE CVP WAVEFORMThe CVP waveform reflects The CVP waveform reflects

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

a – the rise in right atrial pressure caused by atrial systole.

c – the ventricular contraction causes the tricuspid valve to bulge upwards into the right atrium (RA).

x – the decrease in pressure in the RA as the tricuspid valve moves away from the RA during ejection of blood from the right ventricle.

v – the peak in atrial pressure during ventricular systole when the tricuspidvalve is closed.

y – the tricuspid valve opens and blood rapidly empties into the rightventricle during diastole.

NORMAL CVP NORMAL CVP MEASUREMENTSMEASUREMENTS

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 PATIENT MANAGEMENT OF A PATIENT WITH A CVP LINEWITH 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 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 Ensure all connections are secure to prevent exsanguination, introduction of prevent exsanguination, introduction of infection and air emboliinfection and 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 The length of the indwelling catheter should be recorded and regularly should be recorded and regularly monitored.monitored.

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

REMOVAL OF CENTRAL LINEREMOVAL OF CENTRAL LINE

The central venous catheter should be removed as soon as it is no longer needed or if the site

appears infected. In any case, it should not remain in place for longer than five days. A

physician’s order is required for removal

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

TILTED DOWNTILTED DOWNENSURE NO DRUGS ARE ATTACHED AND RUNNING ENSURE NO DRUGS ARE ATTACHED AND RUNNING

VIAVIA 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 UNTIL APPLY DIGITAL PRESSURE WITH GAUZE UNTIL

BLEEDING STOPSBLEEDING STOPS

ARTERIAL LINESARTERIAL LINES

WHAT IS AN ARTERIAL LINEWHAT 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 pressurepressureif patient is on if patient is on

intropic drugsintropic drugsif patient is on if patient is on

vasoactive drugvasoactive drugif patient requiresif patient requires

frequent arterial frequent arterial blood samplingblood sampling

COMPLICATIONS ASSOCIATED COMPLICATIONS ASSOCIATED WITH ARTERIAL LINESWITH ARTERIAL LINES

HYPOVOLAEMIAHYPOVOLAEMIAACCIDENTAL INTR-ARTERIAL ACCIDENTAL INTR-ARTERIAL

INJECTION OF DRUGSINJECTION OF DRUGSLOCAL 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

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