MOD 2 - Lines and Tubes

Central Lines (CVC's)

a long flexible catheter that is inserted through the skin and placed with the tip residing within the SVC

Function of Central Lines

• reliable, long term infusions of one or more medications simultaneously

• to alleviate the need to continually access short-term peripheral IV's in patients (chemotherapy, dialysis, frequent blood testing)

three categories of Central Venous Catheters (CVC)

• Non-Tunneled Catheters

• Tunneled Catheters 

• Peripherally Inserted Central Catheter (PICC).

Non-Tunneled Catheters (NTC) Patient Condtion

acute

NTC Common Insertion Sites

subclavian or jugular veins, with a preference towards the right side as it takes a direct path to the SVC

Tunneled CVC's Patient Condition

generally well and physically able but require ongoing venous access for outpatient therapies such as chemotherapy, dialysis, or long-term antibiotic treatment

Common Tunneled CVC's

• Hickman lines

• Broviac lines

• Permacath catheters (used for dialysis)

Tunneled CVC's Insertion Process

a portion of the catheter is routed through a subcutaneous tunnel created beneath the chest skin which then enters one of the central veins (jugular or subclavian)

Tunneling Technique Benefit

helps reduce the risk of infection and contamination while also providing added protection against accidental dislodgement or damage

Port-a-Cath Line

Another type of tunneled catheter which does not have any portion of the catheter outside the body, and accessed by a specific needle with extension tubing

PICC Lines Insertion Site

peripherally located on the upper arm, typically the basilic vein

PICC Line Usage

for long or short term use in independent patients who are mostly well, but require regular vascular access for treatment

PICC Line Benefits

offer reduced infection rate compared to other CVC's, reduced risks during insertion and ease of maintenance for the patient

CVC Ideal Tip Location

• transversely between the SVC and the right atrium which is at level of the carina T4-5

• vertically in the same plane as the SVC

Effects of Catheters that terminate before the SVC

associated with greater risk of infection and thrombosis

CVC Tip Termination for administration of maintenance medications and fluids

within SVC

• 2cm above carina

• 3-4 cm right of the vertebral process

Effects of CVC located below the carina

associated with risk of cardiac tamponade

CVC Tip Termination for long term use and infusion of irritating medications (chemo)

terminates within cavo-atrial junction (~2VB down carina)

Atrial Placement

• what

• risks

• not intended however, they may advance unintentionally with changes in patient position, or migration, over time

• cardiac tamponade, tissue erosion and perforation

Most frequent malpositioned CVC insertion site

jugular vein

Catheter placed in azygos vein

PICC line placed in Internal mammary vein

Left jugular coiling of CVC

Pulmonary Artery Flow Catheters (PAC's)

• what

• aka

• catheters that measure cardiac output and blood pressures within the heart, typically placed within the heart

• also known as Swan- Ganz Catheters

PACS Patient Conditions

often following open heart or chest surgery and pulmonary hypertension

PACS Features

• aid in the diagnosis of right or left heart failure

• evaluate stress on heart function

• monitor oxygen saturation levels between the right and left side of the heart

• temperature monitoring

• diastolic pressure of the left heart

• delivering fluids and medications

PACS Insertion Process and Radiographic Appearance

via the subclavian, jugular or femoral vein and advanced into RA, then with a balloon tip, the catheter is then floated into the right or left pulmonary artery, radiographically the catheter makes a large U-turn within the heart

NG/OG Tube Patient Conditions

• declining patient consciousness

• to reduce the risk of aspiration

• stroke with asphasia

• cognitive decline resulting in poor nutritional consumption

• oral/esophageal tumor causing obstruction

• gastric decompression

NG/OG Tube Ideal Placement

weighted tip at least 10cm past the gastro-esophageal junction = 10 cm below the diaphragm and overlying the gastric bubble

NG/OG Tube Complications

• mild local tissue trauma from the insertion

• perforation of the esophagus or mediastinum

• pneumothorax

• aspiration

• hemorrhage and death

Most commonly mispositioned NG/OG tubes

• entering the lung right bronchus

• making a u-turn within the esophagus directing the tip back toward the larynx

Ideal Radiographic Image of NG/OG Tube

• tube should be seen parallel to the spine and slightly to the left

• enters the stomach at the level of the diaphragm, where the tube will curve according to the shape of the stomach

• weighted tip oriented downward or slightly angled right or left

NG visualized within the right bronchial tree.

NG looped within the esophagus

Insufficient NG insertion

NG in LLL

NG visualized in costophrenic recess

Chest Tubes

inserted using sterile technique, into the pleural space most often at the bedside by care providers to either remove fluid or air

Chest Tube Patient Conditions

• may be from critically acute departments such as ICU, CCU or Trauma

• non acute patients with chronic lung pathologies or illnesses that cause build up of fluid within the chest

Chest Tube “safe zone“ insertion site

fifth intercostal space, slightly anterior to the mid-axillary line

Main Purpose of Chest Tubes

drainage; either air or fluid from within the pleural space

Common 2 types of Chest Tubes

• large bore

• small bore

Large Bore Chest Tubes

• for pneumothorax

• directed to the superior, anterior portions of the pleural cavity, ideally in the apices - since air rises

Small Bore Chest tubes

• for fluid drainage

• directed inferiorly and posteriorly towards dependent fluid collection spaces - since fluid "sinks"

Complications of chest tube insertion

• pneumothorax

• surgical emphysema

• tension pneumothorax

• hemorrhage

Pneumothorax induced during insertion of pleural drainage catheter

Subcutaneous emphysema (air within the soft tissue) due to pneumothorax and incomplete insertion of chest tube for pleural effusion drain

Pacemaker (PM)

an electromechanical device that regulates the heart rate by providing low levels of electrical stimulation to the heart muscle

Primary Purpose of a Pacemaker (PM)

to maintain an adequate heart rate, either because the heart’s natural pacemaker is not fast enough, or there is a block in the heart’s electrical conduction system

Temporary PMs Usage

to treat short-term heart problems, such as a slow heartbeat that’s caused by a heart attack, heart surgery, or an overdose of medicine

Permanent PMs Usage

to control long-term heart rhythm problems

Types of Pacemakers

• Internal = implanted inside the patient's chest

• External = generally temporary and the bulk of the instrument remains outside the patient's chest in a pocket created under the skin

Pacemaker Insertion

• performed under fluoroscopic guidance within the diagnostics department (cardiac catheterization lab or imaging department)

• in the operating room, ICU, or CCU with a portable C-arm (but rare)

Patient should not _ within 24hr post pacemaker insertion

patients are not allowed to abduct or elevate their left arm to prevent dislodging of the catheter and pacemaker

Respiratory tubes

allow assistance to a patient if they require aid for air to pass into the lungs

• bypass of an area of blockage

• protect the airway from aspiration of secretions

• to control respiration

two types of respiratory tubes

• tracheostomy tube

• oral/nasal tracheal tube (Endotracheal (ET))

Endotracheal Tube Insertion Site

introduced into the trachea through the oral cavity (OTT) or nasal passage

Endotracheal (ET) Tube Tip Optimal Locations

• ET tube should be located in the trachea 5-7cm superior to the carina

• as neck position affects the location of the distal tip, a radiograph performed with the neck in neutral position

Complications of ET Tubes - ET Tube Inserted Too Far

lung collapse of the contralateral side

Complications of ET Tubes - Esophageal Insertion

ET tubes inserted into the esophagus will result in ventilation of the abdomen and can be fatal

Complications of ET Tubes - Pneumomediastinum and Surgical Emphysema

introduction of air in surrounding areas

Tracheostomy Tubes

• surgical opening in the anterior neck into the trachea to permit long term mechanical ventilation

• ETT ventilation is not recommended beyond 14-21 days, due to complications, thus it gets replaced by a TT

Optimal Location for Tracheostomy Tubes

distal tip is positioned at midpoint between the upper end of the tube and the carina, typically 6cm above the carina