MRAD 2410: Module 2 (Tubes & Lines)

list the 2 types of specialty catheters

central lines/central venous catheters (CVCs), pulmonary artery flow directed catheters (PACs)

structurally, what is a central line

a long flexible catheter

where are CVCs inserted into (3)

through the skin and into the SVC, the cavo-atrial junction, or within the RA

role of CVCs

allow for long term infusions of meds

what type of patients require CVCs

those in critical condition + requiring continuous support with multiple IV meds

T or F: CVCs allow for large volumes of fluid boluses

true

why are CVCs a useful method for delivering medicine

many meds are irritating to peripheral blood vessels

list the 3 categories of CVCs

non-tunneled catheters, tunneled catheters, peripherally inserted central catheter

purpose of non-tunneled catheters

allow for fast and reliable venous access for meds and blood draws

describe now NTCs are inserted at bedside

inserted, then secured with a dressing until placement is confirmed

once NTC placement is confirmed, how are they secured

via sutures

which vessels are NTCs inserted into

subclavian or jugular veins

NTCs are inserted into either subclavian or jugular veins. which side of the body is preferred + why

right side; most direct path to the SVC

what are tunneled catheters used for

for patients that are well and physically able, but require ongoing venous access for outpatient therapies

list 3 common types of tunneled catheters

hickman lines, broviac lines, permacath catheters

structurally/functionally, how is a tunneled catheter different from a non tunneled catheter

tunneled also go to the jugular or subclavian veins, but first it is tunneled through subcutaneous tissue beneath the chest skin

role of the tunnel of tunneled catheters

reduces the risk of infection, provides protection against accidental dislodgement

describe how the tunnel for tunneled catheters is created

inject local anesthetic by making two small incisions; one at the vein entry site and one 2-3 inches below the clavicle. skin is separated from underlying tissue = the tunnel. catheter is positioned in the vein and some is threaded through while the rest remains outside the skin

what is this

tunneled catheter (CVC)

a port-a-cath line is a type of tunneled catheter. describe how it’s structure is unique

contains an implantable port rather than an external port. it is sutured in place beside the ribcage, and the pt will not have any part of the catheter dangling

peripherally inserted central catheters (PICCs) are a type of CVC. describe the insertion site

upper arm and into the basilic vein

role of PICCs

for long or short term use for pts who are mostly well but require vascular access for treatment

benefits of PICCs

reduced infection rates compared to other CVCs, have reduced risks during insertion, and are easy for the pt to take care of

what is this

PICC

which catheter type does this image show (be specific)

non tunneled CVC

what is the entry point shown in this image for a non-tunneled CVC

subclavian vein

what type of catheter is shown in this image (be specific)

non-tunneled CVC

what is the insertion point shown for this non-tunneled CVC

jugular vein

what catheter type is shown in this image (be specific)

tunneled CVC

what catheter type is shown in this image (be specific)

PICC (type of CVC)

how do we see CVCs on xrays

they all have a radiopaque strip

what must a tech pay attention to when doing a CXR to confirm CVC line placement

don’t dislodge the line (it’s not secure yet), have good technique for visualization, position correctly so placement confirmation is accurate

what do techs do for follow up imaging after a CVC placement

we compare with previous images to see if the line has moved/withdrawn

T or F: techs are qualified to access central lines

FALSE

techs are not qualified to access central lines, but what can we use them for

injecting contrast media, however the radiology nurse or pts ward nurse must access all connections and disconnections

tip location for CVCs vary, but roughly where should they terminate

between SVC and RA

ideally, the tip of the CVC should be in the same vertical plane as which structure

SVC

what is the result if the catheter terminates before the SVC (ie in the subclavian or brachiocephalic veins)

higher risk of infection, thrombosis

role of catheters that terminate in the SVC

fluid injections

for SVC placements of catheters, what will this look like on a radiograph

tip ends 2cm above the level of the carina

for CVC placements in the SVC, what risks are there if the tip extends below the level of the carina

cardiac tamponade

role of the catheters that terminate at the cavo-atrial junction

long term use, infusion of meds that might be irritating (ie chemo)

for catheters that terminate at the cavo-atrial junction, what will the tip look like on a radiograph

ends approx 2 vertebral bodies below the level of the carina

T or F: typically we don’t want catheters to terminate in the atrium

true

why would catheters migrate to the RA over time

due to patient position over time

list 3 risks associated with atrial CVC placement

cardiac tamponade, tissue erosion, perforation

after CVC placement, which factor (other than time) could contribute to the migration of the catheter tip into the RA

lines are placed when the pt is supine or trendelenburg, so it might move once the pt is placed upright

in which scenario would we want the catheter to end in the RA

for hemodialysis

undiagnosed CVC malpositioning leads to ___ and ___

morbidity and mortality

give some examples of what issues result from undiagnosed CVC malpositioning (6)

vessel erosion, perforation, venous thrombis formation, subsequent migration, catheter dysfunction, cranial infusion rather than central circulation

most frequently malpositioned CVCs are within which vessel

jugular vein

most frequently malpositioned CVCs are within the jugular vein. describe this

tip points up the vein rather than down towards the heart

where does the PICC line terminate in this image

RA

pulmonary artery flow directed catheters (PACs) are the second type of specialty catheter in this course. what is their role

measure cardiac output and BP within the heart

what type of patients need PACs

ones that require intensive monitoring (ie following open heart surgery, and pulmonary hypertension)

what does the info we get from PACs help us with

diagnosing heart failure, elevated stress on heart function, and monitoring oxygen saturation between both sides of the heart

T or F: PACs aid in continuous temp monitoring

true

T or F: PACs can deliver fluids + meds

true

brand name of PACs

Swan-Ganz catheter

which vessels are PACs inserted into (3)

subclavian, jugular, or femoral veins

where does the tip of the PAC end

RA

what do we do with the PAC once it’s in the RA

using a balloon tip, we direct it to the left or right pulmonary artery

what does a PAC look like radiographically

seen making a large U turn within the heart shadow, tip rests in the pulmonary trunk below the carina or is to the right/left of the carina in one of the pulmonary arteries

when are NG/OG tubes used

when the pt is unable to swallow safely

NG/OG tubes are used when a pt cannot swallow safely. when might this be (5)

declining consciousness, stroke, aphasia, cognitive decline resulting in poor nutrition, oral/esophageal tumor resulting in obstruction

how do we use NG tubes during an overdose

NG tube is inserted to suction gastric contents, or provide a neutralizing agent (activated charcoal)

T or F: prior to initial NG tube use, a CXR is done to confirm placement

true

how do we see NG and OG tubes on a radiograph

they have a radiopaque strip

during xrays, if a pt has an NG/OG tube that is being used for a feeding pump, what must we not do + why

don’t place them supine; increases risk of aspiration

describe NG/OG tube insertion and handling

the approx length is externally marked prior to insertion, then tube is lightly secured, then CXR is done to confirm placements. once confirmed, the tube is firmly secured with tape or neck ties

ideal NG tube position

tip should be at least 10cm past the gastro-esophageal junction

on an xray, where will the end of the NG tube be

10cm below the diaphragm, aka over the gastric bubble

complications of NG tubes (6)

tissue trauma, esophageal/mediastinal perforation, pneumothorax, aspiration, hemorrhage, rarely death

list 2 common mispositions for NG tube placement

tip entering the right bronchus, or looping back towards the larynx

describe the optimal appearance of an NG tube on an xray (not just where it ends)

should be // to the spine and slightly left of the SPs, enters the stomach at the diaphragm level, curves with the shape of the stomach and passes the gastric bubble, the weighted tip should point downwards and be slightly angled L/R

describe the incorrect NG tube placement

ends in the right bronchial tree

describe the incorrect NG tube placement

loops back within the esophagus

describe the incorrect NG tube placement

insufficient insertion; needs to be longer

where do chest tubes go

into the pleural space

role of chest tubes

remove fluid or air

what types of pts need chest tubes

those from ICU, CCU, or trauma, or non-acute pt with chronic lung pathologies where fluid builds up in the chest

where are chest tubes inserted

5th intercostal space + slightly anterior to the midaxillary line

what are chest tubes connected to outside of the body

drainage receptables or mechanical suction units

list the two types of chest tubes

large bore, small bore

what are large bore chest tubes used for

pneumothorax (air removal)

what are small bore chest tubes used for

fluid drainage

how are we able to see chest tubes on radiographs

they have a radiopaque strip

where in the body will large bore chest tubes terminate + why

superior/anterior portions of the pleural cavity; air rises

where in the body will small bore chest tubes terminate + why

inferiorly/posteriorly; fluid sinks

before positioning a pt with a chest tube, how are chest tubes secured and how do we move with them

they’re secured to the mattress via kelly clamps, so we remove the clamps before positioning

complications of chest tube insertion (4)

pneumothorax, surgical emphysema, tension pneumothorax, hemorrhage

role of pacemakers

maintain adequate heart rate; used when the natural pacemaker isn’t fast enough or if there is a block in the electrical conduction system

how do we program modern pacemakers

externally programmable, the cardiologist can set optimum pace mode for each pt

what are temporary PMs used for + give examples

treat short term heart problems; slow heartbeat from a heart attack, surgery, or overdose

what are permanent PMs used for

long term heart rhythm problems

how does the pacemaker work

provides low levels of electrical stimulation to the heart muscle; it can sense the pts heart rate and provide stimulation when needed

describe internal pacemakers

surgically implanted inside the pt chest

how big is the generator component of an internal pacemaker

size of a matchbox, weighs 20g

describe external pacemakers

bulk remains in a pocket created under the skin, the leads are placed transvenously

rules for 24h post insertion for pacemakers

pt cannot abduct or lift their left arm