Akses vena central

Anestesiologi dan Reanimasi RSUD Tasikmalaya

AKSES SENTRAL
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

Pemilihan lokasi
Lokasi
Subklavia

Benefit
Vena besar Tolerate thd high flow Mudah perawatan Tdk mengganggu aktifitas pasien Insiden sepsis rendah

Resiko
Dekat dgn apeks paru Dekat dgn arteri subklavia Sulit mengontrol jika terjadi perdarahan Resiko pneumotoraks

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Pemilihan lokasi
Lokasi
Jugularis eksterna

Benefit
Mudah terlihat Aman untuk pasien-pasien dgn koagulapati coagulopathy Insiden pneumotoraks kecil

Resiko
Suli insersi krn sudut vena di klavikula Kemungkinan kateter ke lengan atau kepala

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Pemilihan lokasi
Lokasi
Jugularis interna

Benefit
Vena besar Mudah dicari Mudah di akses Pendek, arah lurus ke vena cava superior Insiden pneumotoraks kecil

Resiko
Tidak comfort buat pasien Perawatan pembalutan sulit Dekat dgn arteri karotis Mudah kontaminasi Sulit perawatan pd pasien dgn trauma leher

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Site Selection
Site
Femoral

Pros
Easy access Large vessel Good access during resuscitation

Cons
Decreased mobility Increased risk of thrombosis, phlebitis & infection Easily contaminated Close to femoral artery Dressing difficult to maintain

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Yang harus dilakukan setelah insersi

Foto Thoraks (mutlak)

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

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 P&P 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)

Dressings
Equipment needed:

Sterile transparent dressing Sterile gloves Alcohol/acetone swabs Betadine swabs Benzoin sticks

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Dressings
Procedure:

Cuci tangan Jelaskan prosedur kepada pasien Gunakan sarung tangan, 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

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

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,

COMPLICATIONS OF PICC LINES

Occlusion or clotting - opened with urokinase

Mechanical phlebitis
Thrombosis Malposition Catheter leak

Accidental removal

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

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

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

Complications
Immediate

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

Complications
Delayed

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

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

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

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

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

HEMODYNAMIC 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

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

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

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