CVC LINE ART LINES IN ICU

1. CENTRAL LINESCENTRAL LINES
ANDAND
ARTERIAL LINESARTERIAL LINES
SHARON HARVEYSHARON HARVEY
26/01/0426/01/04

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

8. CENTRAL VENOUSCENTRAL VENOUS
PRESSUREPRESSURE

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.

17. CENTRAL
VENOUS
PRESSURE
CVP
BLOOD VOLUME
(INCREASED
VENOUS RETURN
RAISES CVP
CARDIAC
COMPETENCE
(REDUCED
VENTRICULAR
FUNCTION
RAISES CVP)
INTRATHORACI
C AND
INTRAPERITON
EAL PRESSURE
(RAISES CVP)
SYSTEMIC
VASCULAR
RESISTENCE
(INCREASED
TONE RAISES
CVP)

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

21. ARTERIAL LINESARTERIAL LINES

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

30. QUESTIONS????QUESTIONS????