akses vena central

8/13/2019 Akses Vena Central

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Akses vena central

Anestesiologi dan ReanimasiRSUD Tasikmalaya


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AKSES SENTRAL

Central lines are IV access lines placed in the high flow,large centrally located veins of the body

External Jugular VeinInternal Jugular Vein

Subclavian VeinFemoral Vein

Used for long-term IV Fluid administration, totalparenteral nutrition, vasopressors, or if patient has noaccessible peripheral veins

Inserted by physicians assisted by nursesNurses role: supplies, consent, explanation to patient,sedation, positioning patient, line care


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12/6/2013

Pemilihan lokasi

Lokasi Benefit ResikoSubklavia Vena besar

Tolerate thdhigh flowMudahperawatanTdkmenggangguaktifitas pasienInsiden sepsisrendah

Dekat dgnapeks paruDekat dgn arterisubklaviaSulitmengontrol jikaterjadiperdarahanResikopneumotoraks


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12/6/2013

Pemilihan lokasi

Lokasi Benefit ResikoJugularis

eksterna

Mudah terlihat

Aman untukpasien-pasiendgnkoagulapaticoagulopathy

Insidenpneumotorakskecil

Suli insersi krn

sudut vena diklavikulaKemungkinankateter kelengan atau

kepala


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12/6/2013

Pemilihan lokasi

Lokasi Benefit ResikoJugularisinterna

Vena besarMudah dicariMudah di aksesPendek, arahlurus ke venacava superiorInsidenpneumotoraks

kecil

Tidak comfortbuat pasienPerawatan

pembalutansulitDekat dgnarteri karotisMudah

kontaminasiSulit perawatanpd pasien dgntrauma leher


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12/6/2013

Site Selection

Site Pros ConsFemoral Easy access

Large vessel Good accessduringresuscitation

Decreasedmobility

Increased riskof thrombosis,phlebitis &infection

Easilycontaminated

Close tofemoral artery Dressingdifficult tomaintain


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Yang harus dilakukan setelah insersi

Foto Thoraks (mutlak)Place an occlusive sterile dressingFlush lumens to maintain patencyMonitor site for bleeding

Assess breath soundsAssess circulationAssess for hematomaDocument insertion, site, dressing and flushing


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USING THE CENTRAL LINE

Flush q shift, before and after use with NS. Some placesalso require heparin flushClose clamps when not is useCheck P&P of facility, but usually fluids are changed

every 24 hours, tubing changed every 48-72 hoursDressing is usually changed every 3 daysLine can be used for blood drawing - withdraw andwaste 10 cc, then withdraw blood for samplesIf port becomes clotted, do not use - sometimes portscan be opened up with urokinase (requires a doctorsorder)


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12/6/2013

Dressings

Equipment needed:Sterile transparent dressingSterile glovesAlcohol/acetone swabsBetadine swabsBenzoin sticks


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12/6/2013

Dressings

Procedure:Cuci tanganJelaskan prosedur kepada pasien

Gunakan sarung tangan, secure catheter andremove old dressing carefullyPrepare sterile field and open equipment usingsterile techniqueApply sterile glovesUsing alcohol swabs, begin at insertion site ofcentral line and, working outward in a circularmotion, clean site well. Take care to remove oldblood


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12/6/2013

Dressings

Procedure contd: Use betadine swabs in same way. Allow to dryApply op site to area over central line. Usebenzoin stick around edges to secure op siteLabel dressing change date on op siteDocument dressing changeChange dressing 24 hours after insertion andthen every 72 hours, and PRN (exceptions:Mediport/PICC line dressings are changed every 7days)


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D/C CENTRAL LINE

Maintain sterile techniquePlace patient supine with face turned awayRemove suturesHave patient take a breath, blow it out and Valsalva

Remove line while patient performing valsalva and applypressure for at least five minutesCheck site to make sure no bleedingApply pressure dressingLeave patient in supine position for 30 min


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PICC LINES

Used in patients with moderate to long-term need forfluids, antibiotics, etc.Requires physician orderRequires specialty training - can be inserted by nurses

Must have a consent formUsually placed in median cephalic, basilic or cephalicveinsCan be single or double lumenUsually inserted in dominant arm to encourage bloodflow and reduce dependent edema


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MAINTENANCE OF PICC LINES

Patients can go home with PICC linesFlushed q shift, before and after use with10 cc NS then 2-3cc of Heparin (1000u/cc)

Do not use a syringe smaller than 10ccDressing change is done 24 hours afterinsertion and then q week using sterile

techniqueAssess site q shift for bleeding, redness,swelling, warmth,


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COMPLICATIONS OF PICC LINES

Occlusion or clotting - opened with urokinaseMechanical phlebitisThrombosisMalposition

Catheter leakAccidental removal


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DISCHARGE WITH PICC

Requires patient care conference to coordinate carePatient/Family educationWritten instructionsHome 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 lumensTPN is given through a dedicated portBlood products are given through an 18 guage or largerinfusion port

Dual Lumen LinesBoth lumens open at the distal end of the catheterIncompatible medications should not be givensimultaneouslyBlood should not be drawn from one port whilemedication is infusing in the other


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Triple or Quad Lumen LinesStaggered lumen openingsIncompatible medications may be given at the sametime

Blood sampling should be through the proximal port toavoid contamination by fluids and medications from theother portsCVP monitoring is measured at the distal port


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Complications

ImmediateHemothoraxPneumothorax

Arterial punctureNerve InjuryDysrhythmias

Catheter malplacementCatheter ruptureEmbolusCardiac tamponade


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Complications

DelayedDysrhythmiasCatheter malplacement

Catheter ruptureEmbolusCardiac tamponade

Catheter related infectionThrombosisHydrothorax


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Hickman/Broviac - no valve

Inserted surgically and threaded under the skinUsually inserted in the subclavian vein with the tip2-3 cm from the right atrium

Flush with Saline and Heparin after use & qdayGroshong - 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 portoutside of bodyMediport and Portacaths are the most commonNo dressing is required

Accessed by a Huber needleFlushed with HeparinMore expensive


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HEMODYNAMIC MONITORING

CVP Line - pressure is measured in the great veinsReflects right atrial pressure and, consequently, rightventricular end-diastolic filling pressure - preloadNormal 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 withvenoconstriction, cardiac tamponade, positive-pressure

breathing, strainingNote: The most common cause of right heart failure isleft heart failure


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Pulmonary Artery Catheters - balloon tipped cathetercapable of obtaining several pressure measurementsreflecting the left side of the heartInsertion - inserted either in the jugular vein or the subclavian,

once line threaded into the right atrium the balloon is inflated andthe catheter is guided into the pulmonary artery

Measurements -CVP 4-10 mmHgRA 2-6RV sys 20 - 30 dias 0-5 mean 2-6PA sys 20 - 30 dias 10-20 mean 10-15PCWP 4-12


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CO 4-8 L/minCI (Cardiac Index) 2.5 - 4 (l/min)/BSASVR 900 - 1400 dynes/sec/cm -5 PVR 37- 250 dynes/sec/cm -5

Determining cardiac outputDetermining SVR and PVR-

SVR - systemic vascular resistance (afterload) -the pressure the left ventricle has to push

against to eject the bloodPVR - pulmonary vascular resistance - thepressure the right ventricle has to push againstto eject the blood


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ARTERIAL LINES

Called A-linesUsually placed in the radial artery, but can also be placed inthe brachial or femoralCollateral circulation should be checked prior to insertion

Allen test can/should be used for radial artery placementDoppler can be used for all sites

Once inserted, it should be sutured inProvides a constant readout of BP

Can also be used for drawing blood, particularly ABGs When drawing blood, must waste the first 5-10ccbecause 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 IVtubingA flush bag is connected to the line and kept under 300

mmHg pressure with a pressure bag in order to deliver 3cc/hr to keep line patentCheck institutional policy as to whether flush is NS orHeparinized saline. Standard concentration for heparinizedsaline is 2000 units of Heparin in 500cc NS

Flush is changed every 24 hours. Tubing is usuallychanged every 72 hours.Must get all air bubbles out of the tubing because they willcause a false reading


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PRESSURE LINE SET UP

The pressure tubing is also connected to a transducerThe transducer transmits the pressure change in the fluid,caused by the circulating blood, to the monitor which in turnsdisplays the pressure in numerical form

The transducer must be at the phlebostatic axis (level of theright atrium of the heart). Draw an imaginary line from the 4thintercostal space across the chest and note where it intersectswith an imaginary line drawn mid-axillary down the side of thechest.

The level of the transducer must be raised or lowered with thepatient in order to maintain this level

akses vena central

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