HASEEN central venous catheter and it's monitoring.pptx

Central venous catheter

1. CENTRAL VENOUS CATHETER AND ITS MONITORING PRESENTER-DR HASEEN MODERATOR-DR RAKHI

2. Definition A Central Venous Catheter (CVC) is an indwelling intravenous device that is inserted into a vein of the central vasculature.

3. Indications for CVC 1. Measurement of CVP 2. Drug administration to central circuln 3. Need for frequent I/V access due to pt’s poor peripheral access 4. Parenteral nutrition 5. Long term medication 6. Dialysis 7. Access for PAC

4. Central Venous Pressure Monitoring The central venous pressure (CVP) is the pressure measured in the central veins close to the Right atrium. It indicates mean right atrial pressure and is frequently used to estimate right ventricular preload.

5. Routes of access More commonly used veins 1. Subclavian vein 2. Internal Jugular vein (most preferred because it’s consistent,has predictable anatomy,in alignment with RA, palpable,high success rate and no thoracic duct injury) 3. Femoral vein 4. Basilic vein

6. Less commonly used veins 1. Axillary 2. External Jugular 3. Brachial 4. Cephalic 5. Brachiocephalic

7. Contraindications Absolute Overlying skin or soft tissue infection Thrombophlebitis

8. Contraindications Relative Distorted Anatomy – Trauma, deformity, burns. Infection at the Site of Access – cellulitis Uncooperative patients Proximal Vascular Injury Bleeding disorders & anticoagulation or thrombolytic therapy. 3% complication rate as long as there are no arterial punctures Absolute contraindication for subclavian access Ultrasound guidance is recommended

9. Types Of Central Venous Catheters Non-tunneled central catheters Tunneled central catheters Peripherally inserted central catheters (PICC) Implantable ports

10. Types Of Central Venous Catheters . cont Single & multi-lumen catheters are available in all catheter types Each lumen must be treated as a separate catheter

11. Types Of Central Venous Catheters . cont Open–ended The catheter is open at the distal tip The catheter requires clamping before entry into the system Clamps are usually built into the catheter Requires periodic flushing

12. Types Of Central Venous Catheters . cont Closed-ended A valve is present at the tip of the catheter ( eg . Groshong ®) or at the hub of the catheter( eg . PAS-V®) Clamping is not required as the valve is closed except during infusion or aspiration

13. Types Of Central Venous Catheters . cont Composition Silicone Polyurethane Coatings ♦ Antimicrobial or antiseptic coating ♦ Heparin coating ♦ Radiopaque to confirm tip placement

14. The type of CVC inserted depends on the Type of therapy to be administered Length of therapy (Short term or Long term) Previous devices and complications Patient preference

15. Non Tunnelled Catheters

16. Polyurethane Single or multiple lumens Flow varies depending on size and ID Inserted percutaneously Internal jugular vein Subclavian vein Femoral vein

17. Advantages Easier placement, removal and replacement Economical Disadvantages Highest risk of infections Unused ports must be routinely flushed with heparin solution and clamped Dislodged more easily Temporary - requires frequent exchanges

18. Insertion Informed Consent Sterile technique Adequate skin preparation with sterilizing solution Setup of Equipment Positioning and identifying the landmarks Adequate local analgesia

19. Internal Jugular Vein Right side preferred pleural dome and thoracic duct on left Trendelenburg position(10-15 degrees) Head rotated approximately 15 to the left At the cricoid level while palpating the carotid pulse, introducer needle into the apex of the sternocleidomastoid- clavicular triangle at a 30-40 angle to the skin. Aim the needle caudally towards the patient’s ipsilateral nipple.

20. Subclavian Vein Right side preferred - Supine position, head neutral, arm abducted - Trendelenburg position (10-15 degrees) - Shoulders neutral with mild retraction Junction of the medial and middle thirds of the clavicle. The site of needle insertion lies about 1 cm inferior to the clavicle allowing for the needle to pass under the clavicle. Needle should be parallel to skin Aim towards the supraclavicular notch

21. Femoral Vein Supine/Flat position/external rotation of hip Palpate the femoral artery’s pulse just distal to the inguinal ligament. The femoral vein lies just medial to this.

22. Seldinger technique Use introducing needle to locate vein Wire is threaded through the needle Needle is removed Skin and vessel are dilated Catheter is placed over the wire Wire is removed Catheter is secured in place

23. Post-Catheter Placement Aspirate blood from each port Flush with saline or sterile water Secure catheter with sutures Cover with sterile dressing ( tega-derm ) Obtain chest x-ray for IJ and SC lines

24. 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 Highest risk of infection Risk of DVT Not good for ambulatory patients

25. Tunnelled Catheters

26. Single or multiple lumens Used for long term therapy Inserted surgically Small Dacron ( Polyethylene terephthalate ) cuff sits in subcutaneous tunnel facilitates anchoring of the catheter through granulation and acts as a barrier to infection

27. Advantages Can be left in place indefinitely (if no infection, blockage or thrombosis) Self-care by patient External portion can be repaired

28. Disadvantages Inserted in the OR Requires a dressing & frequent assessments External device Physician must remove

29. Peripherally Inserted Central Catheters

30. Silicone or polyurethane Single or multi-lumen Approximately 40-60 cm long Used for intermediate to long-term therapy Inserted percutaneously Basalic vein Cephalic vein The tip rests in the superior vena cava at the cavo -atrial junction.

31. Advantages Can remain in place for several weeks to a year Can be easily removed Low infection rates External portion can be repaired

32. Disadvantages Low flows Requires a dressing & frequent assessments External device Small gauge PICC not recommended for blood sampling

33. IMPLANTABLE VENOUS ACCESS DEVICE (IVAD)

34. long-term (months to years) single or dual chamber “port” surgically implanted in the subcutaneous tissue, usually in the upper chest Single or double lumen . Each chamber must be managed separately.

35. A non-coring point needle is required to access the device Unused port is flushed every 28 days with Heparin solution

36. Advantages Internal device, no dressing or site care Can be permanent Unrestricted activity Decreased risk of infection No external components to break May be used as long as the device is required, functional.

37. Disadvantages Needle access is required Surgical procedure required to insert/remove Cost

38. Complications Associated With Central Venous Catheters

39. Complications Acute Chronic Complication rate depends on Site Patient factors (illnesses, variations in anatomy) Operator skill and experience.

40. Acute complications Cardiac Dysrhythmias Due to cardiac irritation by the wire or catheter tip. Withdraw the line into the superior vena cava. Always use a cardiac monitor. Haematoma formation – Arterial/Venous puncture Mechanical injury to nearby structures Pneumothorax/ Haemothoarx Atrial wall puncture - pericardial tamponade . Bowel penetration, Bladder puncture, Femoral nerve injury Air embolus Malposition Lost Guide-wire

41. Chronic complications Infections Catheter fragmentation Non-function/Blockage - fibrin builds on and around the catheter and vessel, drug precipitates, lipid deposits Thrombosis/Thromboembolism

42. Air embolism Deadly complication associated with CVC’s Signs and Symptoms Respiratory changes: sudden shortness of breath, cyanosis CVS changes: sudden onset of chest pain, ↑HR, ↓BP CNS changes: altered neurological signs, dizziness, confusion, loss of Consciousness

43. Management Left lateral decubitus with head low Position ( Durant maneuver and Trendelenburg position) Clamp the Central Venous Catheter 100% O2 Direct removal of air from the venous circulation by aspiration from a central venous catheter in the right atrium may be attempted

44. To minimize the chance of air entering the system: Ensure the lumen is clamped prior to opening the system Position the patient so that the insertion site is at or below the level of the heart during insertion and removal of catheter

45. Infections Most frequent and serious complications. Types Local infection – Cellulitis Central Line-Associated Bloodstream Infections (CLABSI)

46. Causative Organisms Staph epidermidis 25-50% Staph aureus 25% Candida 5-10% Risk Factors Cutaneous colonization of the insertion site Moisture under the dressing Prolonged catheter time Technique of care and placement of the central line

47. Evidence-Based Strategies Selected to Reduce CLA-BSIs Hand hygiene Maximal sterile barriers Chlorhexidine for skin asepsis Avoid femoral lines Avoid/remove unnecessary lines

48. CVP MONITORING

49. What is CVP monitoring? It is an invasive procedure threading of CVC inserted into a large central vein (Subclavian, Internal/external Jugular, Median basilin /Femoral) . The catheter’s tip positioned into RA,upper portion of superior vena cava/inferior vena cava (femoral approach). The Physician inserts a catheter through a vein & advances it until its tip lies/near the RA. As no major valves lies @ junction of Venacava & RA,pressure @ end diastole reflects back to catheter

50. Cvp Monitoring with Manometer Articles Required: A tray containing: 1. I/V tubing 2. Manometer set 3. A stopcock if not included in manometer set 4. Indelible ink marking pen 5. NS 6. Adhesive tape 7. Facemask 8. Sterile mask 9. Kidney tray & Paper bag

51. 3 way Stopcock Here upper port is connected to Manometer,right side of port connected to NS and left side of port connected with CVC line

52. Phlebostatic Axis Before Measuring CVP we need to know what’s Phlebostatic Axis. Phlebostatic Axis is used to identify level of RA.

53. CVP WAVEFORM

54. CVP wave Normal central venous pressure (CVP) waveform: 1."a" wave: The "a" wave represents atrial contraction. It occurs just after the P wave of the electrocardiogram (ECG) and coincides with the closing of the tricuspid valve. The "a" wave is typically small and gentle. 2. "c" wave: The "c" wave is caused by the upward movement of the tricuspid valve during ventricular contraction. It occurs between the "a" and "v" waves and is usually small.

55. 3. "x" descent: The "x" descent occurs during early ventricular diastole. It is a downward deflection caused by the downward movement of the tricuspid valve as the ventricle relaxes. 4. "v" wave: The "v" wave represents venous filling during ventricular systole. It occurs just after the T wave of the ECG and reflects the increasing pressure in the right atrium as blood returns from the venous circulation. 5. "y" descent: The "y" descent is a downward deflection that follows the "v" wave. It occurs as the tricuspid valve opens and blood flows from the right atrium to the right ventricle

56. CVP waveform Waveform component Phase of cardiac cycle Mechanical event a wave End diastole Atrial contraction c wave Early systole Isovolumetric ventricular contraction, tricuspid bulge in right atrium v wave Late systole Systolic filling of atrium x decent Mid systole Atrial relaxation Y decent Early diastole Early ventricular filling

57. ◦ Right side function of heart is assessed through evaluation of CVP whereasleft side function of heart is less accurately reflectedby evaluation of CVP,but it may be useful in chronic R&L Heart Failure/for differentiatingR&L Ventricular Infarctions

58. Factors affecting CVP Factors ↑ sing CVP: 1. Hypervolemia 2. Cardiac tamponade 3. Tension pneumothorax 4. Heart failure 5. Pleural effusion 6. Forced exhalation(Raised intrathoracic exp by cough) 7. Pulmonary embolism

59. 8. Pulmonary Hypertension 9. Mechanical Ventilation 10. ↓ sing C.O. 11. Cardiac competence (reduced ventricular function) 12. Blood volume( ↑ sed venous return) 13. Intra-aortic & Intra-peritoneal pressure 14. System Vascular Resistance 15. Application of + ve End Expiratory Pressure (PEEP

60. Factors ↓ sing CVP: 1. Hypovolemia 2. Deep inhalation ( reduced intrathoracic pressure) 3. septic shock( venodilation )

61. CVP MONITORING In CVP monitoring, we insert a catheter through a vein and advances it until its tip lies in or near the right atrium Because no major valves lies at the junction of the vena cava and right atrium, pressure at end diastole reflects back to the catheter. When connected to manometer, the catheter measures CVP an index of right ventricular function. CVP monitoring helps to assess cardiac function, to evaluate venous return to the heart, and to indirectly gauge how well the heart is pumping.

62. METHODS TO MEASURE CVP Indirect method: Inspection of jugular venous pulsation in the neck. Direct method fluid filled manometer connected to central venous catheter. Calibrated transducer.

63. Inspection of jugular venous pulsation in the neck: No valve between right atrium and internal jugular vein Degree of distension and venous wave form reflects information about cardiac function.

64. 2. Fluid filled manometer connected to central venous catheter CVP is measured using a column of water in a marked manometer. CVP is height of the column in cm of H2O when column is at the level of right atrium ADVANTADE: simplicity to measure DISADVANTAGE: 1) inability to analyze the CVP waveform 2) relative slow response of water column to change in intrathoracic pressure

65. METHOD: With the CV line in place, position the patient flat. Align the base of the manometer with the determined zero reference point by using leveling device. Because CVP reflect right atrium pressure, you must align the right atrium with the zero mark on manometer To find right atrium locate the fourth intercostal space at the midaxillary line. Mark the appropriate place on patients chest so that all subsequent recordings will be made using same location. Attach water manometer to pint stand or place it to the next to patient’s chest. Make sure the zero reference point is level with right atrium.

66. The fluid level within the manometer column will fall to the level of the CVP, the value of which can be read on manometer scale which is marked in CM of water therefor giving value of CVP in cmH2O. The fluid level will continue to rise and fall slightly with respiration and average reading should be recorded.

67. 3. Calibrated transducer Automated, electronic pressure monitor. Pressure wave form displayed on an oscilloscope or paper. ADVANTAGE: 1)more accurate 2)direct observation of waveform

68. METHOD : The transducer is fixed at the level of right atrium and connected to patient’s CVP catheter via fluid filled extension tubing. The transducer than ‘zeroed, to atmospheric pressure by turning its 3 way tap so that it is open to the transducer and to room air but closed to patient. The 3 way tap is then turned so that it is now closed to room air and open between patient and transducer. A continue CVP reading measured in mmHg

69. COMLICATION Haemorrhage Pneumothorax Air embolism Arteriovenous fistula Adjacent organ puncture Thrombosis Thrombo embolism Skin infection and necrosis sepsis

70. INTRA ARTERIAL BLOOD PRESSURE MONITORING IBP measurement is often considered to be the gold standard of blood pressure measurement. Despite its increased risk, cost, and need for technical expertise for placement and management, its utility in providing crucial and timely information outweighs its risks in many cases.

71. INDICATION Continuous, real time BP monitoring Planned pharmacological or mechanical cardiovascular manipulation Repeated blood sampling Failure of indirect arterial bp monitoring Supplementary diagnostic information from the arterial waveform

72. BASIC PRINCIPLE The pressure waveform of the arterial pulse is transmitted via the column of fluid, to a pressure transducer where it is converted into electrical signal. The electrical signal is then processed, amplified and converted into a visual display by a microprocessor.

73. ARTERIAL PRESSURE MONITORING SITE radial artery – most commonly used Ulnar artery Brachial artery Axillary artery Femoral artery Dorsalis pedis artery

74. COMPLICATION Hemorrhage Distal ischemia Pseudoaneurysm Arteriovenous fistula Infection Peripheral neuropathy

75. COMPONENT OF AN IBP SYSTEM: Intra arterial cannula Fluid filled tubing Transducer Infusion/flushing system Signal processor, amplifier and display

76. PHYSICAL PRINCIPLES A wave is disturbance that travel through a medium, transferring energy but not matter. One of the simplest waveforms is the sine wave. Fourier analysis: The arterial waveform is clearly not simple sine wave but it can be broken down into a series of many component sine waves. The process of analyzing a complex waveform in terms of its constituent sine waves is called Fourier analysis. Property: Natural frequency Damping coefficient

77. NATURAL FREQUENCY The natural frequency of a system determines how rapid the system oscillates after a stimulus. It is important that IBP system has a very high natural frequency at least eight timed the fundamental frequency of arterial waveform(pulse rate). Therefore, for a system to remain accurate at heart rate of up to 180bpm, its natural frequency must be at least: (180bpm *8)/60sec=24Hz

78. The natural frequency of a system may be increased by Reducing the length and compliance of tubing Reducing the density of the fluid used in tubing Increase the diameter of tubing Commercially available system -200Hz

79. DAMPING: Anything that reduces energy in an oscillating system will reduce the amplitude of oscillation. This is termed damping. Some degree of damping required in for all system(critical damping), But if excessive(overdamping) or insufficient(underdamping) the output will be adversely affected. The damping coefficient reflects forces acting on the system and determines how rapidly it returns to rest after a stimulation.

80. FAST FLUSH TEST Provide a convenient bedside method for determining dynamic response of system. Natural frequency is inversely proportional to the time between adjacent oscillation peaks The damping coefficient can be calculated mathematically, but it is usually determined graphically from amplitude ratio

81. Thank You