Central Lines

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Central Lines

• Becca Maddox
• NURS 2205
• Spring 2002

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CENTRAL LINES

• Central lines are IV access lines placed in the
  high flow, large centrally located veins of the
  body
• External Jugular Vein
• Internal Jugular Vein
• Subclavian Vein
• Femoral Vein
• Used for long-term IV Fluid administration, total
  parenteral nutrition, vasopressors, or if patient
  has no accessible peripheral veins
• Inserted by physicians assisted by nurses
• Nurses role supplies, consent, explanation to
  patient, sedation, positioning patient, line care

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Site Selection
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Site Selection
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Site Selection
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Site Selection
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YOUR ROLE AFTER THE INSERTION

• Obtain a chest x-ray (ask for order if physician
  doesnt mention it)
• Place an occlusive sterile dressing
• Flush lumens to maintain patency
• Monitor site for bleeding
• Assess breath sounds
• Assess circulation
• Assess for hematoma
• Document insertion, site, dressing and flushing

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USING THE CENTRAL LINE

• Flush q shift, before and after use with NS. Some
  places also require heparin flush
• Close clamps when not is use
• Check PP of facility, but usually fluids are
  changed every 24 hours, tubing changed every
  48-72 hours
• Dressing is usually changed every 3 days
• Line can be used for blood drawing - withdraw and
  waste 10 cc, then withdraw blood for samples
• If port becomes clotted, do not use - sometimes
  ports can be opened up with urokinase (requires a
  doctors order)

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Dressings

• Equipment needed
• Sterile transparent dressing
• Sterile gloves
• Alcohol/acetone swabs
• Betadine swabs
• Benzoin sticks

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Dressings

• Procedure
• Wash hands
• Explain procedure to patient
• Apply gloves, secure catheter and remove old
  dressing carefully
• Prepare sterile field and open equipment using
  sterile technique
• Apply sterile gloves
• Using alcohol swabs, begin at insertion site of
  central line and, working outward in a circular
  motion, clean site well. Take care to remove old
  blood

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Dressings

• Procedure contd
• Use betadine swabs in same way. Allow to dry
• Apply op site to area over central line. Use
  benzoin stick around edges to secure op site
• Label dressing change date on op site
• Document dressing change
• Change dressing 24 hours after insertion and then
  every 72 hours, and PRN (exceptions
  Mediport/PICC line dressings are changed every 7
  days)

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D/C CENTRAL LINE

• Maintain sterile technique
• Place patient supine with face turned away
• Remove sutures
• Have patient take a breath, blow it out and
  Valsalva
• Remove line while patient performing valsalva and
  apply pressure for at least five minutes
• Check site to make sure no bleeding
• Apply pressure dressing
• Leave patient in supine position for 30 min

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PICC LINES

• Used in patients with moderate to long-term need
  for fluids, antibiotics, etc.
• Requires physician order
• Requires specialty training - can be inserted by
  nurses
• Must have a consent form
• Usually placed in median cephalic, basilic or
  cephalic veins
• Can be single or double lumen
• Usually inserted in dominant arm to encourage
  blood flow and reduce dependent edema

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MAINTENANCE OF PICC LINES

• Patients can go home with PICC lines
• Flushed q shift, before and after use with 10 cc
  NS then 2-3cc of Heparin (1000u/cc)
• Do not use a syringe smaller than 10cc
• Dressing change is done 24 hours after insertion
  and then q week using sterile technique
• Assess site q shift for bleeding, redness,
  swelling, warmth,

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COMPLICATIONS OF PICC LINES

• Occlusion or clotting - opened with urokinase
• Mechanical phlebitis
• Thrombosis
• Malposition
• Catheter leak
• Accidental removal

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DISCHARGE WITH PICC

• Requires patient care conference to coordinate
  care
• Patient/Family education
• Written instructions
• Home Health for medication administration
• Follow-up care with physician

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TYPES OF CENTRAL LINES

• Central venous catheters may have 1, 2, 3, or 4
  lumens
• TPN is given through a dedicated port
• Blood products are given through an 18 guage or
  larger infusion port
• Dual Lumen Lines
• Both lumens open at the distal end of the
  catheter
• Incompatible medications should not be given
  simultaneously
• Blood should not be drawn from one port while
  medication is infusing in the other

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TYPES OF CENTRAL LINES

• Triple or Quad Lumen Lines
• Staggered lumen openings
• Incompatible medications may be given at the same
  time
• Blood sampling should be through the proximal
  port to avoid contamination by fluids and
  medications from the other ports
• CVP monitoring is measured at the distal port

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Complications

• Immediate
• Hemothorax
• Pneumothorax
• Arterial puncture
• Nerve Injury
• Dysrhythmias
• Catheter malplacement
• Catheter rupture
• Embolus
• Cardiac tamponade

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Complications

• Delayed
• Dysrhythmias
• Catheter malplacement
• Catheter rupture
• Embolus
• Cardiac tamponade
• Catheter related infection
• Thrombosis
• Hydrothorax

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TYPES OF CENTRAL LINES

• Hickman/Broviac - no valve
• Inserted surgically and threaded under the skin
• Usually inserted in the subclavian vein with the
  tip 2-3 cm from the right atrium
• Flush with Saline and Heparin after use qday
• Groshong - 3 way sensitive slit, doesnt require
  clamping, flushed with saline q week

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IMPLANTABLE DEVICES

• Implanted subcutaneously instead of patient
  having a port outside of body
• Mediport and Portacaths are the most common
• No dressing is required
• Accessed by a Huber needle
• Flushed with Heparin
• More expensive

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HEMODYNAMIC MONITORING

• CVP Line - pressure is measured in the great
  veins
• Reflects right atrial pressure and, consequently,
  right ventricular end-diastolic filling pressure
  - preload
• Normal pressure 4-10
• Low - hypovolemia, venodilation,
  negative-pressure ventilators, right ventricular
  assist devices, central venous obstruction,
  decreased venous return
• High - hypervolemia, right-sided heart failure
  with venoconstriction, cardiac tamponade,
  positive-pressure breathing, straining
• Note The most common cause of right heart
  failure is left heart failure

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HEMODYNAMIC MONITORING

• Pulmonary Artery Catheters - balloon tipped
  catheter capable of obtaining several pressure
  measurements reflecting the left side of the
  heart
• Insertion - inserted either in the jugular vein
  or the subclavian, once line threaded into the
  right atrium the balloon is inflated and the
  catheter is guided into the pulmonary artery
• Measurements -
• CVP 4-10 mmHg
• RA 2-6
• RV sys 20 - 30 dias 0-5 mean 2-6
• PA sys 20 - 30 dias 10-20 mean 10-15
• PCWP 4-12

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HEMODYANIC MONITORING

• CO 4-8 L/min
• CI (Cardiac Index) 2.5 - 4 (l/min)/BSA
• SVR 900 - 1400 dynes/sec/cm-5
• PVR 37- 250 dynes/sec/cm-5
• Determining cardiac output
• Determining SVR and PVR-
• SVR - systemic vascular resistance (afterload) -
  the pressure the left ventricle has to push
  against to eject the blood
• PVR - pulmonary vascular resistance - the
  pressure the right ventricle has to push against
  to eject the blood

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ARTERIAL LINES

• Called A-lines
• Usually placed in the radial artery, but can also
  be placed in the brachial or femoral
• Collateral circulation should be checked prior to
  insertion
• Allen test can/should be used for radial artery
  placement
• Doppler can be used for all sites
• Once inserted, it should be sutured in
• Provides a constant readout of BP
• Can also be used for drawing blood, particularly
  ABGs
• When drawing blood, must waste the first 5-10cc
  because diluted with flush

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PRESSURE LINE SET UP

• Arterial lines, CVP Lines and Pulmonary Artery
  Lines (Swan-Ganz) require pressure tubing instead
  of regular IV tubing
• A flush bag is connected to the line and kept
  under 300 mmHg pressure with a pressure bag in
  order to deliver 3 cc/hr to keep line patent
• Check institutional policy as to whether flush is
  NS or Heparinized saline. Standard concentration
  for heparinized saline is 2000 units of Heparin
  in 500cc NS
• Flush is changed every 24 hours. Tubing is
  usually changed every 72 hours.
• Must get all air bubbles out of the tubing
  because they will cause a false reading

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PRESSURE LINE SET UP

• The pressure tubing is also connected to a
  transducer
• The transducer transmits the pressure change in
  the fluid, caused by the circulating blood, to
  the monitor which in turns displays the pressure
  in numerical form
• The transducer must be at the phlebostatic axis
  (level of the right atrium of the heart). Draw an
  imaginary line from the 4th intercostal space
  across the chest and note where it intersects
  with an imaginary line drawn mid-axillary down
  the side of the chest.
• The level of the transducer must be raised or
  lowered with the patient in order to maintain
  this level