C V C Presentation

Lecture in icu King Saud Hospital

1. Central Venous Central Venous
CatheterizationCatheterization
By: Ms. Adnan A. Tander
ICU- Staff Nurse

2. OBJECTIVESOBJECTIVES
Definition
Indications/Purpose
Prerequisite Nursing Knowledge
Relative Contraindications
Complications
Common Approach for CVC Insertion
Patient and Family Education
Patient Assessment and Preparation
Patient Monitoring and Care
CVP Measurement
Documentation/Nurse’s Note
Basic Materials/Equipments

3. Definition:
Central Venous Catheter “Central Line”, “CVC”,
Central Venous Line, Central Venous Access Catheter
– is a catheter placed into a large vein (Internal Jugular, External
Jugular, Subclavian, or Femoral vein), passing through a peripheral
vein and ending in the thoracic/superior vena cava.

5. INDICATIONS/PURPOSEINDICATIONS/PURPOSE
Central Venous Pressure Monitoring
Volume Resuscitation
Cardiac Arrest
Lack of Peripheral Access
Total Parenteral Nutrition
Blood Transfusion
Blood Sampling (frequent blood draws)
Infusion of Concentrated Solutions
Placement of Transvenous Pacemaker
Cardiac Catheterization, Pulmonary Angiography
Hemodialysis

6. • Decide if the line is really necessary.
• Understand and know the normal anatomy and physiology of the
cardiovascular system.
• Advanced cardiac life support knowledge and skills are needed.
• Understand and know the implications, and relative complications
of Central Venous Catheter Insertion.
• Must have knowledge with the common sites for CVC
placement.
• Obtain optimal patient positioning and cooperation.
• Follow strict sterile protocol
• Be familiar with your equipment.
• Obtain chest X-ray post line placement and review it.
• Understand and know how to measure CVP and its normal
values.
BASIC PRINCIPLES AND
PREREQUISITE NURSING KNOWLEDGE

7. RELATIVE RELATIVE
CONTRAINDICATIONSCONTRAINDICATIONS
Bleeding disorders/coagulopathies
(eg. Hemophilia A&B, DIC,
prolonged PT, PTT, INR)
Anticoagulation or thrombolytic therapy
(on continuous IV Heparine infusion, oral Warfarin)
Combative patients
Distorted local anatomy
Cellulitis, burns, severe dermatitis at site
Vasculitis
Presence of pace maker
Fever

8. COMPLICATIONS OF CVC INSERTION
• Pneumothorax

• Tension Pneumothorax

• Delayed Pneumothorax
• Hydrothorax/Hydromediastinum
• Hemothorax
• Arterial Puncture/Laceration
• Bleeding/Hematoma
• Cardiac Dysrythmias
• Air Embolism
• Catheter Malposition
• Catheter Embolism

9. • Pericardial Tamponade
• Tracheal Injury
• Nerve Injury
• Thrombophlebitis
• Pulmonary Embolism
• Sepsis
• Celulitis
• Osteomyelitis
• Septic Arthritis
• Bowel or Bladder Perforation

10. PREVENTIONTREATMENTCLINICAL
MANIFESTATION
COMPLICATIONS
-Proper patient
preparation
-Proper patient
positioning
-Sedation as necessary
-Adequate hydration
status
-Proper patient
preparation
-Proper patient
positioning
-Sedation as necessary
-Adequate hydration
-Reduction of PEEP<
5cmH2O at time of
venipuncture
-Proper patient
preparation
-Proper patient
positioning
-Sedation as needed
-Adequate hydration
status
-Confirmation by chest
x-ray
-Symptomatic treatment
-Small pneumothorax:
*bed rest, Oxygen
-Peumothorax >25%
*chest tube
*Cardiopulmonaryardiopulmonary
supportsupport

-Treatment must be rapid
and aggressive
-Immediate air aspiration
followed by chest tube
-Cardiopulmonary
support
-Confirmation by chest
x-ray
-Chest tube
-Cardiopulmonary
support
-Sudden respiratory
distress
-Chest pain
-Hypoxia/cyanosis
-Decreased breath sounds
-Resonance to percussion
-Most likely to occur in
patients on ventilatory
support
-Respiratory distress
-Cyanosis
-Venous distension
-Hypotension
-Decreased cardiac output
-Slow onset of respiratory
symptoms
-Subcutaneous
emphysema
-Persistent chest pain
or back pain
PNEUMONTHORAX
TENSION
PNEUMOTHORAX
DELAYED
PNEUMOTHORAX

11. PREVENTION
TREATMENTCLINICAL
MANIFESTATION
COMPLICATIONS
-Proper patient
preparation
-Proper patient
positioning
-Sedation as needed
-Adequate hydration
status
-Correct coagulopathies
before insertion
-Adequate hydration
status
-Avoid multiple pricking
-Correct coagulopathies
before insertion
-Avoid multiple pricking
-Adequate hydration
status
-Stop infusion
-Confirmation by chest
x-ray
-Cardiopulmonary support
-Confirmation by chest
x-ray
-Chest tube
-Thoracotomy for arterial
repair if indicated
-Application of pressure
for 3-5mins following
removal of needle
-Elevate head of bed
-Chest tube as indicated
-Thoracotomy for arterial
repair if indicated
-Dyspnea
-Chest pain
-Muffled breath sounds
-Low-grade fever
-High glucose level of
chest drainage
-Respiratory distress
-Hypovolemic shock
-Hematoma in the neck
with jugular insertions
-Return of bright red
blood in the syringe
under high pressure
-There is Pulsation
-Respiratory distress
-Hemorrhagic shock
-Bleeding from catheter
site
-Deviation of trachea with
large hematoma in the
neck
-Hemothorax
HYDROTHORAX/
HYDRO-
MEDIASTINUM
HEMOTHORAX
ARTERIAL PUNCTURE/
LACERATION

12. PREVENTIONTREATMENTCLINICAL
MANIFESTATION
COMPLICATIONS
-Correct coagulopathies
before insertion
-Adequate hydration
status
-Avoid multiple pricking
-Avoid entry into the
heart
with guide wire/catheter
-Observe cardiac monitor
-Application of pressure
to the insertion site
-Thoracotomy for arterial
repair
-Tracheostomy for
tracheal deviation from
hematoma
-Withdarw the guidewire
or catheter from the
heart
-Pharmacologic treatment
of persistent arrythmias
-Adequate hydration
status
-Head-down tilt or
Trendelenburg position
during catheter insertion
-Bleeding from insertion
site
-Hematoma formation
-Tracheal compression
-Respiratory distress
-Carotid compression
-PVCs, SVTs, Vtach
-Premature atrial
contractions
-Atrial flutter
-Sudden cardiovascular
collapse
-Tachypnea
-Apnea
-Tachycardia
-Hypotension
-Cyanosis
-Anxiety
-Paresis/stroke
-Sudden cardiovascular
collapse
-Coma
-Cardiac arrest
BLEEDING/
HEMATOMA
(VEMOUS/ARTERIAL
)
CARDIAC
DYSRYTHMIAS
AIR EMBOLISM

13. PREVENTIONTREATMENTCLINICAL
MANIFESTATION
COMPLICATIONS
-Proper patient
positioning
-Extreme caution in
venipuncture
-Extreme caution in
venipuncture
-Position the patient in a
high Fowler’s position to
allow gravity to correct
jugular tip malposition
-Repositioning of
catheter with guide wire
under fluoroscopy or
new venipuncture
-Catheter removal
-Location of fragment on
x-ray
-Transvenous retireval of
catheter fragment
-Thoracotomy if
indicated
-Treatment must be rapid
and aggressive
-Stop infusions
-Aspiration through the
catheter
-Emergency pericardio-
centesis
-Emergency thoracotomy
-Aspiration of air
-Pain in ear or neck
-Swishing sound in ear
with infusion
-Sharp anterior chest pain
-Pain in shoulder blade
-Cardiac dysrythmias
-No blood return on
aspiration
-Observation on chest
x-ray
-Cardiac dysrythmias
-Chest pain
-Dyspnea
-Hypotension
-Tachycardia

-Retrosternal/epigastric
pain, pleural effusion
-Dyspnea, hypotension
-Venous engorgement of
face and neck
-Restlessness, confusion
-Paradoxical pulse
-Cardiac arrest
CATHETER
MALPOSITION
CATHETER
EMBOLISM
PERICARDIAL
TAMPONADE

14. PREVENTIONTREATMENTCLINICAL
MANIFESTATION
COMPLICATIONS
-Extreme caution in
venipuncture
-Extreme caution in
venipuncture
-Avoid catheter exchange
in veins with thrombosis
-Strict aseptic technique
during catheter insertion
-Proper and adequate skin
preparation
-Emergency reintubation
for punctured ETT cuff
-Aspiration of air in
mediastinum
-Remove catheter if
suspected brachial plexus
injury
-Chest x-ray
-Lung perfusion scan
-Cardiopulmonary
support
-Hot compression for 48
to 72 hours
-Removal of catheter
-Subcutaneous
emphysema
-Pneumomediastinum
-Air trapping between the
chest wall and the pleura
-Respiratory distress with
puncture of ETT cuff
-Tingling/numbness in
arm
or fingers
-Shooting pain down the
arms
-Paralysis
-Chest pain, Dyspnea
-Tachycardia, Coughing
-Anxiety, Fever
-Redness, tenderness,
swelling along the course
of the vein
-Pain in the upper
extremity or shoulder

TRACHEAL INJURY
NERVE INJURY
PULMONARY
EMBOLISM
THROMBO-
PHLEBITIS

15. APPROACH FOR CVC INSERTION APPROACH FOR CVC INSERTION
1. INTERNAL JUGULAR APPROACH
Positioning
- Right side preferred-lower pleural dome and thoracic duct on left
- Trendelenburg position(10-15 degrees)
- Head turned slightly away from the site of venipuncture
2. SUBCLAVIAN APPROACH
Positioning
- Right side preferred
- Supine position, head neutral, arm abducted
- Trendelenburg position (10-15 degrees)
- Shoulders neutral with mild retraction
3. FEMORAL APPROACH
Positioning
- Supine/Flat position

16. Location Advantage Disadvantage
Internal
Jugular
• Bleeding can be recognized
and controlled
• Malposition is rare
• Less risk of pneumothorax
• Risk of carotid artery puncture
• Pneumothorax is possible
Subclavian
• Most comfortable for
conscious patient
• Highest risk of bleeding
• Vein is non-compressible/deep vein
• Highest risk of Pneumothorax
Femoral
• Easy to find vein
• No risk of Pneumothorax
• Preferred site for
emergencies and CPR
• Fewer bad complications
•Highest risk of infection
• Risk of DVT
• Not good for ambulatory
patients

18. Internal Jugular Central Approach

20. Femoral artery
Femoral nerve
Femoral Vein
NAVEL

21. Post-Catheter PlacementPost-Catheter Placement
Aspirate blood from each port
Flush with saline or sterile water
Secure catheter with sutures
Cover properly and neatly with sterile dressing
(tega-derm) or Opsite
Obtain chest x-ray for IJ and SC lines
Measure CVP
Documentation/Nurse’s Note

22. PATIENT AND FAMILY EDUCATION
• Explain the procedure to the patient and family, and
reinforce information given.
Rationale: Prepares the patient and family and reduces
anxiety.
• Explain the required positioning for the procedure and the
importance of not moving during the insertion
(for conscious patient).
Rationale: Encourages cooperation and reduces anxiety.
• Explain the need for sterile technique and that the patient’s
face may be covered.
Rationale: Decreases patient anxiety and elicits cooperation.

23. PATIENT ASSESSMENT
AND PREPARATION
Patient Assessment
• Assess Vital Signs and pulse Oximetry
Rationale: Provides baseline data.
• Assess cardiac and pulmonary status
Rationale: Some patients may not tolerate a supine or
Trendelenburg position for extended periods.
• Assess coagulophatic status/recent anticoagulant/
thrombolytic therapy
Rationale: These patients are more likely to have
complications related to bleeding.

24. Patient Preparation
• Ensure that the patient and family understand the pre-
procedural teaching. Answer questions as they arise and
reinforce information as needed.
Rationale: Evaluates and reinforces understanding of
previously taught information.
•Ensure that Informed Consent was obtained
Rationale: Protects the rights of the patient and makes a
competent decision possible for the patient; however under
emergency circumstances, time may not allow for this
formed to be signed.
• If needed, performed endotracheal/tracheostomy suctioning on
ventilated patients before the procedure.
Rationale: Minimize the risk of contamination of the sterile field and the
need to interrupt the procedure for suctioning.

25. Reportable ConditionsRationalePatient Monitoring
And Care
• Abnormal vital signs
• Changes in level of consciousness
(if patient is conscious)
Identifies signs and symptoms of
complications and allows for
immediate interventions.
1. Monitor the patient’s vital signs
and assess level of consciousness
before, during, and after the
procedure.
• Abrupt and sustained changes in
pressure
• Abnormal waveforms
Ensures that catheter is in the proper
location for monitoring. Allows
assessment of a, c and v waves and
measurement of pressure.
2. If the catheter was placed for
obtaining CVP measurement, assess
the waveform.
• Bleeding or hematomaPost insertion bleeding may occur in
a patient with coagulopathies or
arterial punctures, multiple attempts
at vein access, or with the use of
through-the-needle introducer
designs for insertion.
3. Observe the catheter site for
bleeding or hematoma every 15 to 30
minutes for the first 2 hours after
insertion.
• Diminished or muffled heart sounds
• Absent or diminished breath sounds
unilaterally
Abnormal heart and lung sounds may
indicate cardiac tamponade,
pneumothorax, or hemothorax.
4. Assess heart and lung sounds
before and after the procedure.
• Signs and symptoms of
complications
May decrease mortality if recognized
Early.
5. Monitor for signs and symptoms of
complications.
PATIENT MONITORING AND CARE

26. CENTRAL VENOUS PRESSURE MEASUREMENT
Definition
The Central Venous Pressure (CVP) or the Right Atrial Pressure
(RAP) - is the pressure measured at the tip of a catheter placed
within a central vein or the Right Atrium (RA).
Purpose:
• To assess patient’s fluid volume status.
• To assess preload of the heart
• Provide information about the Right Ventricular function and
allows for evaluation of right-sided heart hemodynamics and
evaluation of patient response to therapy.

27.  METHODS FOR MEASURING CVP
• Water Manometer Flush System – provide only a
numerical value and measure centimeters of water
pressure (cm of H2O). Water manometer values will
be higher than mercury readings.
• Hemodynamic Monitoring/Mercury Transducer System
- allow for analysis of the waveform and measurement of
the pressure by mm Hg pressure.
Formula for conversion: cm H2O÷1.36 = mm Hg
 Normal CVP value: 2 to 7 mm Hg = 3 to 10 cm H2O

28. BASIC PRINCIPLES IN MEASURING CVP
• Follow strict standard precautions, wash hands before and after
measuring CVP to reduce transmission of microorganism.
• Wear gloves (mask and gown for isolated cases).
• Put patient on supine/flat position (if no contraindication).
• To ensure accuracy of measurement, locate the phlebostatic axis/
mid axilla of the patient and place the zero level of the water
manometer at the level of the phlebostatic axis by using carpenter’s
level.
• Wipe each port with alcohol swab before and after using.
• Flush the line with plain NS and check for back-flow/patency
before measuring CVP.
• Check CVP at the proximal port.
• To avoid inconsistency, always check CVP at the same port and
same position.

29. CONDITIONS CAUSING INCREASED CVP
• Elevated vascular volume
• Increased cardiac output (hyper dynamic cardiac function)
• Depressed cardiac function ( RV infarct, RV failure)
• Cardiac tamponade
• Constrictive pericarditis
• Pulmonary hypertension
• Chronic left ventricular failure
CONDITIONS CAUSING DECREASED CVP
• Reduced vascular volume
• Decreased mean systemic pressure (eg, late shock states)
• Venodilation (drug induced)

31. DOCUMENTATIONDOCUMENTATION
Patient and Family Education
Vital Signs
Document the name of procedure and describe what
you did including the preparation of the patient
Indication for procedure
Insertion site , type and size of catheter and
level/centimeter mark at skin
Medications Administered
Date and time of procedure

32. • Type of dressing applied
• Initial CVP value
• Informed consent
• Nursing Interventions
• Patient Tolerance
• Confirmation of Placement i.e. chest x-ray
• Any complications and the interventions
taken

33. NURSE’S NOTES SAMPLE:
11/08/1432 (1000HR) – THE PATIENT HAS NO PERIPHERAL LINE
ACCESS AND IN NEED OF INTRAVENOUS ACCESS DUE TO SEVERE
SHOCK. SO, UNDER LOCAL ANESTHESIA, A 7 FRENCH, TRIPLE
LUMEN CENTRAL VENOUS CATHETER WAS INSERTED BY DR.
BASSAM TAHA AT THE RIGHT SUBCLAVIAN AND SUTURED IN
PLACE AT LEVEL 15 CM. THE AREA WAS CLEANED AND DRESSING
(OPSITE) WAS APPLIED PROPERLY AND NEATLY. CHEST X-RAY
WAS TAKEN AND SHOWING THE TIP OF THE CATHETER PROPERLY
IN PLACE WITHIN THE SUPERIOR VENA CAVA. INITIAL CVP
MEASURED 10 CM H2O. THE PATIENT TOLERATED THE PROCEDURE
WITHOUT ANY COMPLICATIONS. VITAL SIGNS ARE STABLE WITH
HR 75Bpm, RR 20 CYCLES/MIN, BP 120/80 mm Hg, SPO2 98% ON SIMV
VENTILATORY SUPPORT, TPR 37.5 DEGREES CENTIGRADE. PRIOR TO
THE PROCEDURE, CONSENT WAS SECURED.

34. Basic Materials/EquipmentsBasic Materials/Equipments
•Catheter of choice (single/double/triple lumen), size
•Face mask, surgical caps, sterile gloves, sterile gowns, drapes
•Antiseptic solution/Povidone-iodine scrub, gauze sponges, dressing set/suture
set
•Syringes(1cc,10cc),Three-way stopcock, 2-0 silk/nylon suture curve
•Alcohol, Lidocaine 1%, Heparinized Saline Flush, Transparent dressing/
Tegaderm/Opsite
• Sterile IV Set , Plain Normal Saline
• Water Manometer
• Carpenter’s level

35. References References
Clinical Procedures in Emergency Medicine,
Roberts and Hedges, 4
th
edition, 2004
Clinician’s Pocket Reference, Leonard Gomella,
8
th
edition, 1997
Atlas of Human Anatomy, Frank Netter, 2
nd

edition, 1997
 AACN Procedure Manual for Critical Care,
Debra J. Lynn-McHale/Karen K.Carlson, 4
th

Edition

36. Thank you!