2. LEARNING OUTCOMESLEARNING OUTCOMES
THE STUDENT SHOULD BE ABLETHE STUDENT SHOULD BE ABLE
TO:-TO:- IDENTIFY A CENTRAL LINE ANDIDENTIFY A CENTRAL LINE AND
ARTERIAL LINEARTERIAL LINE
DISCUSS THE INDICATIONS FORDISCUSS THE INDICATIONS FOR
CENTRAL LINES AND ARTERIAL LINESCENTRAL LINES AND ARTERIAL LINES
DISCUSS THE COMPLICATIONSDISCUSS THE COMPLICATIONS
ASSOCIATED WITH CENTRAL LINESASSOCIATED WITH CENTRAL LINES
AND ARTERIAL LINESAND ARTERIAL LINES
ARTICULATE THE MANAGEMENT OF AARTICULATE THE MANAGEMENT OF A
PATIENT WITH A CENTRAL LINEPATIENT WITH A CENTRAL LINE
AND/OR ARTERIAL LINEAND/OR ARTERIAL LINE
3. WHAT IS A CENTRAL LINEWHAT IS A CENTRAL LINE
It is a catheter thatIt is a catheter that
provides venousprovides venous
access via theaccess via the
superior vena cava orsuperior vena cava or
right atriumright atrium
4. COMMON CENTRAL LINECOMMON CENTRAL LINE
INSERTION SITESINSERTION SITES
Right internal jugularRight internal jugular
left internal jugularleft internal jugular
right subclavianright subclavian
left subclavianleft subclavian
femoral (as a lastfemoral (as a last
resort)resort)
Or peripherallyOr peripherally
inserted centralinserted central
catheters (PICC)catheters (PICC)
which are inserted viawhich are inserted via
the antecubital veinsthe antecubital veins
(basilic vein is the(basilic vein is the
best) in the arm andbest) in the arm and
is advanced into theis advanced into the
central veinscentral veins
5. TYPES OF CENTRAL LINETYPES OF CENTRAL LINE
SINGLE LUMENSINGLE LUMEN
TRIPLE LUMENTRIPLE LUMEN
QUADRUPLEQUADRUPLE
LUMENLUMEN
QUINTUPLE LUMENQUINTUPLE LUMEN
6. CENTRAL LINESCENTRAL LINES
Indications for CVP lines are:-Indications for CVP lines are:-
fluid resuscitationfluid resuscitation
Parenteral feedingParenteral feeding
measurement of central venous pressuremeasurement of central venous pressure
poor venous accesspoor venous access
administration of irritant drugsadministration of irritant drugs
7. COMPLICATIONSCOMPLICATIONS
FOLLOWING CVP LINEFOLLOWING CVP LINE
INSERTIONINSERTION
Malposition of theMalposition of the
cathetercatheter
haematomahaematoma
arterial puncturearterial puncture
pneumothoraxpneumothorax
haemorrhagehaemorrhage
sepsissepsis
air emboliair emboli
Catheter embolismCatheter embolism
ThrombosisThrombosis
HaemothoraxHaemothorax
Cardiac tamponadeCardiac tamponade
Cardiac arrhythmiasCardiac arrhythmias
9. WHAT IS CENTRAL VENOUSWHAT IS CENTRAL VENOUS
PRESSUREPRESSURE
IS THE PRESSURE WITHIN THEIS THE PRESSURE WITHIN THE
SUPERIOR VENA CAVA OR THE RIGHTSUPERIOR VENA CAVA OR THE RIGHT
ATRIUMATRIUM
10. CVP READINGS ARE USED:-CVP READINGS ARE USED:-
TO SERVE AS A GUIDE TO FLUIDTO SERVE AS A GUIDE TO FLUID
BALANCE IN CRITICALLY ILL PATIENTSBALANCE IN CRITICALLY ILL PATIENTS
TO ESTIMATE THE CIRCULATINGTO ESTIMATE THE CIRCULATING
BLOOD VOLUMEBLOOD VOLUME
TO ASSIST IN MONITORINGTO ASSIST IN MONITORING
CIRCULATORY FAILURECIRCULATORY FAILURE
11. CENTRAL VENOUSCENTRAL VENOUS
PRESSURE MONITORINGPRESSURE MONITORING
THIS IS A HELPFUL TOOL IN THETHIS IS A HELPFUL TOOL IN THE
ASSESSMENT OF CARDIAC FUNCTION,ASSESSMENT OF CARDIAC FUNCTION,
CIRCULATING BLOOD VOLUME, VASCULARCIRCULATING BLOOD VOLUME, VASCULAR
TONE AND THE PATIENT’S RESPONSE TOTONE AND THE PATIENT’S RESPONSE TO
TREATMENTTREATMENT
HOWEVER, CVP SHOULD NOT BEHOWEVER, CVP SHOULD NOT BE
INTERPRETED SOLELY BUT ININTERPRETED SOLELY BUT IN
CONJUNCTION WITH OTHER SYSTEMICCONJUNCTION WITH OTHER SYSTEMIC
MEASUREMENTS, AS ISOLATED CVPMEASUREMENTS, AS ISOLATED CVP
MEASUREMENTS CAN BE MISLEADINGMEASUREMENTS CAN BE MISLEADING
12. METHODS OF CVPMETHODS OF CVP
MONITORINGMONITORING
There are two methods of CVP monitoringThere are two methods of CVP monitoring
manometer system:manometer system: enables intermittentenables intermittent
readings and is less accurate than thereadings and is less accurate than the
transducer systemtransducer system
transducer system:transducer system:enables continuousenables continuous
readings which are displayed on a monitor.readings which are displayed on a monitor.
13. MONITORING WITHMONITORING WITH
TRANSDUCERSTRANSDUCERS
Transducers enable the pressure readingsTransducers enable the pressure readings
from invasive monitoring to be displayedfrom invasive monitoring to be displayed
on a monitoron a monitor
To maintain patency of the cannula a bagTo maintain patency of the cannula a bag
of normal saline or heparinised salineof normal saline or heparinised saline
should be connected to the transducershould be connected to the transducer
tubing and kept under continuoustubing and kept under continuous
pressure of 300mmHg thus facilitating apressure of 300mmHg thus facilitating a
continuous flush of 3mls/hrcontinuous flush of 3mls/hr
14. PROCEDURE FOR CVP MEASUREMENTPROCEDURE 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) ANDPOSITION THE PATIENT SUPINE (IF POSSIBLE) AND
ALIGN THE TRANSDUCER WITH THE MID AXILLAALIGN 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 ANYDOCUMENT THE READING AND REPORT ANY
CHANGES OR ABNORMALITIESCHANGES OR ABNORMALITIES
15. THE CVP WAVEFORMTHE CVP WAVEFORM
The CVP waveform reflects changes inThe CVP waveform reflects changes in
right atrial pressure during the cardiacright atrial pressure during the cardiac
cyclecycle
16. NORMAL CVPNORMAL CVP
MEASUREMENTSMEASUREMENTS Central venous presure monitoring shouldCentral 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 limitedAn isolated CVP reading is of limited
value; a trend of readings is much morevalue; a trend of readings is much more
significant and should be viewed insignificant and should be viewed in
conjuncton with other parameters e.g. BPconjuncton with other parameters e.g. BP
and urine output.and urine output.
18. MANAGEMENT OF A PATIENTMANAGEMENT OF A PATIENT
WITH A CVP LINEWITH A CVP LINE
Monitor the patient for signs ofMonitor 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 riskbeing infused in order to minimise the risk
of accidental bolus injectionof accidental bolus injection
If not in use, flush the cannula regularly toIf not in use, flush the cannula regularly to
help prevent thrombosis. A 500ml bag ofhelp prevent thrombosis. A 500ml bag of
0.9% normal saline should be maintained0.9% normal saline should be maintained
at a pressure of 300mmHg.at a pressure of 300mmHg.
19. Ensure all connections are secure toEnsure all connections are secure to
prevent exsanguination, introduction ofprevent exsanguination, introduction of
infection and air emboliinfection and air emboli
Observe the insertion site frequently forObserve the insertion site frequently for
signs of infection.signs of infection.
The length of the indwelling catheterThe length of the indwelling catheter
should be recorded and regularlyshould be recorded and regularly
monitored.monitored.
CVP lines should be removed whenCVP lines should be removed when
clinically indicatedclinically indicated
20. REMOVAL OF CENTRAL LINEREMOVAL OF CENTRAL LINE
THIS IS AN ASEPTIC PROCEDURETHIS IS AN ASEPTIC PROCEDURE
THE PATIENT SHOULD BE SUPINE WITH HEADTHE PATIENT SHOULD BE SUPINE WITH HEAD
TILTED DOWNTILTED DOWN
ENSURE NO DRUGS ARE ATTACHED AND RUNNINGENSURE 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 FORIF THERE IS RESISTENCE THEN CALL FOR
ASSISTANCEASSISTANCE
APPLY DIGITAL PRESSURE WITH GAUZE UNTILAPPLY DIGITAL PRESSURE WITH GAUZE UNTIL
BLEEDING STOPSBLEEDING STOPS
DRESS WITH GAUZE AND CLEAR DRESSING EGDRESS WITH GAUZE AND CLEAR DRESSING EG
TEGADERMTEGADERM
22. WHAT IS AN ARTERIAL LINE?WHAT IS AN ARTERIAL LINE?
AN ARTERIAL LINEAN ARTERIAL LINE
IS A CANNULAIS A CANNULA
USUALLYUSUALLY
POSITIONED IN APOSITIONED IN A
PERIPHERALPERIPHERAL
ARTERYARTERY
SUCH ASSUCH AS
Radial arteryRadial artery
brachial arterybrachial artery
dorsalis pedis arterydorsalis pedis artery
femoral arteryfemoral artery
23. INDICATIONS FOR USINGINDICATIONS FOR USING
ARTERIAL LINEARTERIAL LINE
Ease of accessEase of access
ContinuousContinuous
monitoring of arterialmonitoring of arterial
blood pressureblood pressure
if patient is onif patient is on
intropic drugsintropic drugs
if patient is onif patient is on
vasoactive drugvasoactive drug
if patient requiresif patient requires
frequent arterialfrequent arterial
blood samplingblood sampling
24. COMPLICATIONS ASSOCIATEDCOMPLICATIONS ASSOCIATED
WITH ARTERIAL LINESWITH ARTERIAL LINES
HYPOVOLAEMIAHYPOVOLAEMIA
ACCIDENTAL INTR-ARTERIALACCIDENTAL INTR-ARTERIAL
INJECTION OF DRUGSINJECTION OF DRUGS
LOCAL DAMAGE TO ARTERYLOCAL DAMAGE TO ARTERY
28. THE ARTERIAL WAVEFORMTHE ARTERIAL WAVEFORM
The arterial waveformThe arterial waveform
reflects the pressurereflects the pressure
generated in thegenerated in the
arteries followingarteries following
ventricular contractionventricular contraction
and can be describedand can be described
as having:-as having:-
Anacrotic notchAnacrotic notch
Peak systolicPeak systolic
pressurepressure
Dicrotic notchDicrotic notch
Diastolic pressureDiastolic pressure
29. 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 THETHE PROCEDURE SHOULD BE EXPLAINED TO THE
PATIENTPATIENT
TAKE DRESSING OFF LINETAKE DRESSING OFF LINE
REMOVE ARTERIAL LINE ENSURING THAT THEREMOVE ARTERIAL LINE ENSURING THAT THE
ENTRY SITE IS COVERED WITH GAUZEENTRY SITE IS COVERED WITH GAUZE
APPLY DIGITAL PRESSURE FOR AT LEAST 5APPLY 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 ASASSESS THE PERIPHERAL CIRCULATION AS
THROMBOSIS CAN OCCUR AFTER REMOVALTHROMBOSIS CAN OCCUR AFTER REMOVAL
Why would the femoral vein be used as a last resort?
ALWAYS EXPLAIN ANY PROCEDURE TO THE PATIENT
HOW DO WE DO THIS?
WHY DO WE LIE THE PATIENT SUPINE?
OFF TO PATIENT OPEN TO AIR AND PRESS ZERO ON THE MONITOR. THIS REMOVES EXTRANEOUS PRESSURE
TO ENSURE A CORRECT TRACE
A wave: right atrial contraction (P wave on the ECG)If the A wave is elevated the patient may have right ventricular failure or tricuspid stenosis.
C wave: tricuspid valve closure (follows QRS complex on the ECG).
V wave: pressure generated to the right atrium during ventricular contraction, despite the tricuspid valve being closed (latter part of the T wave on the ECG)
Transparent dressings should be used to permit continuous monitoring of the site. If infection of the CVP line is suspected blood cultures should be taken following removal of the line. The catheter tip should be sent for M C & S.
Thereby avoiding the discomfort of frequent punctures of the artery eg tests for blood gases, serial blood lactate levels, full blood count, u&e’s etc.
HYPOVOLAEMIA – ACCIDENTAL DISCONNECTION OF TUBING FROM THE CANNULA CAN RESULT IN SEVERE HAEMORRHAGE AND HYPOVOLAEMIA
NO DRUGS SHOULD BE ADMINISTERED THROUGH THE ARTERIAL LINE AS IT CAN CAUSE DISTAL ISCHAEMIA AND NECROSIS WITH SOMETIMES PERMANENT DAMAGE
LOCAL DAMAGE TO ARTERY – THIS IS THE MOST COMMON COMPLICATION. IT IS IMPORTANT TO KEEP AN EYE ON THE DISTAL END EG FINGERS WATCH FOR SIGNS OF CHANGE IN TEMPERATURE, MOTTLING OR BLANCHING PARTICULARLY WHEN THE LINE IS FLUSHED.