Line Simulation PIV

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Line SimulationPIVs, Arterial Lines, and
Central Lines

• Stephanie I. Byerly, M.D.
• Vapor Camp

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Types of Lines

• Peripheral Intravenous Line
• Arterial Line
• Central Line
• Multiple lumen Catheters
• Cordis

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Peripheral Intravenous Line

• Indications
• IV access for drug and fluid administration

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Peripheral Intravenous Line

• Device Mechanics
• Angiocatheter
• 14 26 gauge
• 14/16 gauge catheters
• Catheter/needle device
• Safety features

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Peripheral Intravenous Line

• Placement Technique
• Prep area with alcohol
• Apply tourniquet
• Look and feel for vein
• Introduce catheter assess for blood return
• Connect tubing to hub connector
• Place dressing

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Peripheral Intravenous Line

• Contraindications
• Lymph node dissection / Mastectomy
• Infection at site
• Edema at site

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Peripheral Intravenous Line

• Complications
• Phlebitis
• Cellulitis
• Sepsis
• Extravasation
• Infiltration
• Embolism

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Arterial Line

• Indications
• Continuous, real-time blood pressure monitoring
• Planned pharmacologic or mechanical
  cardiovascular manipulation
• Repeated blood sampling
• Failure of indirect arterial blood pressure
  measurement
• Supplementary diagnostic information from the
  arterial waveform
• Determination of volume responsiveness from
  systolic pressure or pulse pressure variation

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Arterial Line

• Cannulation Sites
• Radial artery
• Ulnar artery
• Brachial artery
• Axillary artery
• Superficial temporal
• Femoral
• Dorsalis pedis
• Posterior tibial

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Arterial Line

• Complications
• Distal ischemia, pseudoaneurysm, arteriovenous
  fistula
• Hemorrhage, hematoma
• Arterial embolization
• Local infection, sepsis
• Peripheral neuropathy
• Arterial injury
• Misinterpretation of data
• Misuse of equipment

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Arterial Line

• Contraindication
• Ischemic limb
• Infection at site
• Raynauds Syndrome

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Arterial Line

• Arterial Line Catheters/Kits
• Intravenous angiocatheter
• Integrated guidewire catheter assembly
• Seldinger technique kit

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Arterial Line

• Additional Supplies
• Sterile prep solution
• Sterile drapes
• Sterile gloves
• Local anesthetic
• Wrist dorsiflexion device
• Ultrasound
• Tape
• Dressing

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Arterial Line

• Components
• Arterial catheter
• Extension tubing
• Stopcocks
• Flush devices
• Transducer
• Amplifier
• Recorder

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Arterial Line

• Increased risk of vascular complications
• Vasospastic arterial disease
• Previous arterial injury
• Thrombocytosis
• Protracted shock
• High dose vasopressor administration
• Prolonged cannulation
• Infection

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Arterial Line

• Allen Test
• Identify patients at high risk for ischemic
  complications from radial artery cannulation
• Not reliable in predicting adverse ischemic events

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Arterial Line

• Techniques for placement
• Mild wrist dorsiflexion with wrist resting on
  soft pad
• Prepped with sterile solution
• Local anesthetic injected subcutaneously/intraderm
  ally
• Arterial puncture after palpation
• Attach transducer system
• Caution when leaving wrist in dorsiflexed
  position median nerve injury

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Arterial Line

• Techniques for placement
• Ultrasound
• Transfixion technique
• Front/back wall of artery punctured
• Needle withdrawn and catheter withdrawn into
  vessel lumen
• Attach transducer system

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Arterial Line

• Arterial waveform results from ejection of blood
  from the left ventricle into the aorta during
  systole, followed by peripheral arterial runoff
  of the stroke volume during diastole
• Systolic components follow the EKG R wave and
  consist of a steep pressure upstroke, peak, and
  decline and corresponds to the period of left
  ventricular systolic ejection
• Downslope is interrupted by dicrotic notch, then
  continues its decline during diastole after the
  EKG T wave and reaches nadir at end-diastole

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Arterial Line

• Dicrotic notch approximates timing of aortic
  valve closure
• Systolic upstroke appears 120-180 msec after EKG
  R wave
• Interval reflects
• Spread of electrical depolarization through the
  ventricular myocardium
• Isovolumic left ventricular contraction
• Opening of the aortic valve
• Left ventricular ejection
• Transmission of aortic pressure wave to radial
  artery
• Transmission of pressure signal from arterial
  catheter to pressure transducer

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Arterial Line

• Monitor displays numeric values for the systolic
  peak and end-diastolic nadir pressures and mean
  pressure
• Mean pressure is equal to the area beneath the
  arterial pressure curve divided by the beat
  period and averaged over a series of consecutive
  heartbeats

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Arterial Line

• The arterial blood pressure waveform is a
  periodic complex wave that can be produced by
  Fourier analysis which recreates the original
  complex pressure wave by summing series of
  simpler sine waves of different amplitudes and
  frequencies
• The sine waves that sum to produce the complex
  wave have frequencies that are multiples or
  harmonics of the fundamental frequency.
• 6 10 harmonics are required to provide
  distortion free reproduction of most arterial
  pressure waveforms.

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Arterial Line

• Waveform must be accurately displayed on monitor
• Displayed pressure signal is influenced by the
  arterial catheter, extension tubing, stopcocks,
  flush devices, transducer, amplifier, and
  recorder
• Blood pressure monitoring systems are underdamped
• Elasticity
• Mass
• Friction
• These three properties determine the systems
  operating characteristics
• Natural frequency
• Damping coefficient

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Arterial Line

• If the monitoring system has a natural frequency
  that is too low, frequencies in the monitored
  pressure waveform will overlap the natural
  frequency of the measurement system
• As a result the system will resonate and pressure
  waveforms recorded will be exaggerated or
  amplified
• Overshoot, ringing, or resonance
• Recorded systolic blood pressure overestimates
  the true intra-arterial blood pressure -
  Underdamped

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Arterial Line

• Overdamped arterial pressure waveform is
  recognized by slurred upstroke, absent dicrotic
  notch and loss of fine detail
• Falsely narrowed pulse pressure, MAP may remain
  accurate

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Arterial Line

• Damping Coefficient
• Damping coefficient low underdamped
• Damping coefficient high - overdamped

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Arterial Line

• Monitoring System Components
• Intra-arterial catheter
• Extension tubing
• Stopcocks and in-line blood sampling set
• Pressure transducer
• Continuous-flush device
• Electronic cable connecting to the display screen

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Arterial Line

• Components
• Stopcocks
• Blood sampling and allow transducer to be exposed
  to air for zero reference value
• Allows for needleless blood sampling ports
• In-line aspiration system
• Degrade the dynamic response and exacerbate
  systolic arterial pressure overshoot

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Arterial Line

• Flush Device
• Continuous slow 1-3 ml/hr of saline or
  heparin(1-2 units/ml)
• Spring loaded valve for periodic, high pressure
  flushing of catheter and extension tubing

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Arterial Line

• Transducer Zeroing and Leveling
• Pressure transducer zeroed, calibrated, and
  leveled to appropriate position
• Expose transducer to atmospheric pressure
• Depress the zero button on the monitor
• Establishes zero pressure reference value
  ambient atmospheric pressure

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Arterial Line

• Leveling
• Leveling assigns the zero reference point to a
  specific position on the patients body
• Transducer placed at a level that will best
  estimate aortic root pressure
• Levels adjusted to midchest position in the
  midaxillary line
• Sitting craniotomy leveled at ear
• Lateral decubitus - at heart level

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Arterial Line

• Distal Pulse Amplification
• Distal sites of cannulation reveal morphologic
  changes in the arterial waveform
• As the wave travels from central aorta to the
  periphery, the arterial upstroke becomes steeper,
  the systolic peak becomes higher, the dicrotic
  notch appears later, the diastolic wave becomes
  more prominent, and the end-diastolic pressure
  becomes lower
• Higher systolic pressure, lower diastolic
  pressure and wider pulse pressure
• Means similar

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Arterial Line

• Pressure Wave Reflection
• Influences shape of arterial waveform
• As blood flows from aorta to the radial artery,
  mean pressure decreases only slightly due to
  little resistance to flow
• Arteriolar level mean drops as vascular
  resistance increases
• High resistance to flow diminishes pressure
  pulsations in small downstream vessels but acts
  to augment upstream arterial pressure pulsations
  due to pressure wave reflection

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Arterial Line

• Pressure Wave Reflection
• Morphology of the waveform and precise values of
  systolic and diastolic blood pressure vary
  throughout the body under normal conditions in
  otherwise healthy individuals

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Arterial Line

• Arterial Blood Pressure Gradients
• Peripheral vascular disease
• Patient positioning
• Shock
• Medications
• Temperature
• Cardiopulmonary bypass

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Arterial Line

• Arterial Pressure Monitoring and Volume
  Responsiveness
• Variations in arterial blood pressure during PPMV
• Result from changes in intrathoracic pressure and
  lung volume that occur during the respiratory
  cycle
• Greatest clinical use diagnosis of hypovolemia

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Arterial Line

• SPV
• Inspiratory and expiratory components by
  measuring the increase (delta up) and decrease
  (delta down) in systolic pressure
• In mechanically ventilated patient, normal SPV is
  7 to 10 mm Hg, with up being 2 to 4 mm hg and
  down being 5 to 6 mm Hg
• Hypovolemia causes a dramatic increase in SPV
  especially the delta down component

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Systolic Pressure Variation (SPV)
PPV
Increased lung volumes
Increased intrathoracic pressure
Displaces pulmonary venous reservoir
Decrease in systemic venous return and right
ventricular preload
Reduces left ventricular afterload
Early Expiration
Propel blood left heart, increasing left
ventricular preload
Reduced right ventricular stroke volume crosses
pulmonary vascular bed and leads to reduced
ventricular filling
Increased left ventricular stroke Volume and an
increase in systemic arterial pressure
Left ventricular stroke volume falls and
systemic arterial blood pressure decrease
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Central Venous Cannulation

• Indications for Central Venous Cannulation
• CVP monitoring
• Pulmonary artery catheterization and monitoring
• Transvenous cardiac pacing
• Temporary hemodialysis
• Drug administration
• Concentrated vasoactive drugs
• Hyperalimentation
• Chemotherapy
• Agents irritating to peripheral veins
• Prolonged anitbiotic therapy

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Central Venous Cannulation

• Indications for Central Venous Cannulation
• Rapid infusion of fluids for trauma or major
  surgery
• Aspiration of air emboli
• Inadequate peripheral intravenous access
• Sampling site for repeated blood testing

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Central Venous Cannulation

• Choose catheter type based on therapeutic
  interventions
• Multi-port catheter
• Single lumen large bore catheter
• Pulmonary artery catheter
• Pacing wire

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Central Venous Cannulation

• Site Selection
• Indication for monitoring
• Patients underlying medical condition
• Clinical setting
• Skill and experience of the physician performing
  the procedure

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Central Venous Cannulation

• In patients with a severe bleeding diatheses, it
  is best to choose a puncture site at which
  bleeding from the vein or adjacent artery is
  easily detected and controlled with local
  compression

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Central Venous Cannulation

• Sites for Cannulation
• Internal Jugular Vein right preferable to left
• Subclavian Vein
• External Jugular Vein
• Femoral Vein
• Axillary and other peripheral veins

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Central Venous Cannulation

• Right Internal Jugular Approach
• Aseptic prep
• Trendelenburg position
• Avoid extreme leftward neck rotation
• Landmarks include sternal notch, clavicle, and
  sternocleidomastoid muscle
• EKG monitoring

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Central Venous Cannulation

• Left Internal Jugular Vein Approach
• Cuppola of pleura higher on left
• Thoracic duct Injury
• Left IJ vein often smaller than right
• Left IJ has a greater degree of overlap of
  carotid
• Catheter must transverse the innominate vein
• Less familiarity with left IJ insertion

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Central Venous Cannulation

• Subclavian Vein
• Emergency volume resuscitation
• Long term intravenous therapy
• Dialysis
• Lower risk of infection than IJ or femoral
• Ease of insertion in trauma patients with c
  collar
• Increased patient comfort

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Central Venous Cannulation

• Subclavian Vein Approach
• Aseptic technique
• Small roll between shoulders
• Trendelenburg position
• Puncture 2-3 cm below midpoint of clavicle
• Highest risk of pneumothorax

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Central Venous Cannulation

• External Jugular Vein Approach
• Minimal risk of pneumothorax or arterial puncture
• Difficulty advancing J wire and vein cannulation
  with dilator

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Central Venous Cannulation

• Femoral Vein Approach
• Commonly uses in burn or trauma patients, during
  surgical procedures involving the head, neck, and
  upper part of the thorax, and during CPR
• Risk of femoral artery or femoral nerve injury
• Perform below the inguinal ligament medial to the
  palpated femoral artery
• Provides intra-abdominal venous pressure
  measurements that appear to agree closely with
  pressures measured in the SVC in mechanically
  ventilated patients

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Central Venous Cannulation

• Femoral Vein Approach
• Risk of thromboembolic and infectious
  complications
• Risk of vascular injury intra-abdominal or
  retroperitoneal hemorrhage
• Prevent ambulation

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Central Venous Cannulation

• Axillary Vein Approach
• Allows for accurate SVC pressures
• Decreased risks compared to other approaches

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Central Venous Cannulation

• Peripherally inserted central venous catheters
  (PICCs)
• Placed for long term intravenous therapy
• Placed for patients with difficult IV access
• Low risk, usually placed with local anesthesia at
  bedside
• Usually placed by non-physicians
• Obtained through anticubital veins preferably
  basilic vein
• Flexible nonthrombogenic silicone catheters
• CVP measured via PICC is slightly higher than CVP
  catheters

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Central Venous Cannulation

• Ultrasound Guided Placement
• Fewer needle passes
• Decreased time for placement
• Increased overall success rates
• Fewer complications
• Most successful with IJ approach

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Central Venous Cannulation

• Ultrasound Guided Placement
• Two dimensional ultrasound guidance 7.5 to
  10-MHz transducer protected by a sterile sheath
• Ultrasound probe held in nondominant hand and
  puncture made with dominant hand
• Vein and artery appear as two circular black
  structures
• Vein is compressible
• Artery appears pulsatile
• Transverse or longitudinal views
• Subclavian vein can be difficult to visualize

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Central Venous Cannulation

• X-Ray Confirmation
• X-ray should always be obtained to appropriate
  placement
• Optimal placement below clavicles and about the
  third rib
• Rule out pneumothorax
• Rule out hemothorax

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Central Venous Cannulation

• Complications of Central Venous Pressure
  Monitoring/Line Placement
• Mechanical
• Vascular injury
• Arterial
• Venous
• Hemothorax
• Respiratory compromise
• Airway compression from hematoma
• Tracheal, laryngeal injury
• Pneumothorax

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Central Venous Cannulation

• Complications
• Nerve injury
• Arrhythmias
• Subcutaneous / mediastinal emphysema
• Thromboembolic
• Venous thrombosis
• Pulmonary embolism
• Air embolism
• Catheter or guidewire embolism

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Central Venous Cannulation

• Complications
• Infectious
• Insertion site infection
• Catheter infection
• Bloodstream infection
• Endocarditis
• Misinterpretation of data
• Misuse of equipment

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Central Venous Cannulation

• CVP measured at the junction of the vena cava and
  right atrium and reflects the driving force for
  filling the right atrium and ventricle
• CVP or right atrial pressure in part reflects the
  relationship of blood volume to the capacity of
  the venous system
• CVP also reflects the functional capacity of the
  right ventricle
• Frank-Starling curve higher right heart filling
  pressures are required to maintain ventricular
  stroke output when ventricular contractility is
  impaired

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Central Venous Cannulation

• Normal CVP in awake spontaneously breathing
  patient ranges from 1 to 7 mmHg.
• CVP waveform consists of five phasic events
• Three peaks - a, c, and v waves
• Two descents x and y waves
• Three systolic components c wave, x descent, v
  wave
• Two diastolic components y descent and a wave
• These patterns can be altered by conduction
  abnormalities

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Central Venous Cannulation

• CVP monitoring provides estimate of circulating
  blood volume and right ventricular preload
• Spontaneous breathing lower CVP with
  inspiration
• Mechanical breathing higher CVP with
  inspiration

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