Central Venous

Lines
Edrey Oliver
BMS13091388
INTRODUCTION
Central venous access is defined as placement
of a catheter such that the catheter is inserted
into a venous great vessel.
The venous great vessels include the superior
vena cava, inferior vena cava, brachiocephalic
veins, internal jugular veins, subclavian veins,
iliac veins, and common femoral veins.
INDICATION
Long term parenteral nutrition
Chemotherapy or other vesicant or irritating
solutions
Administration of large volumes of intravenous
fluids
Long term antibiotics
IV medications (when peripheral access is limited)
Central venous pressure monitoring
Hemodialysis

DURATION OF USE 2-12 weeks

 STERILE TECHNIQUE

For the physician, sterile technique

means wearing a surgical cap, procedure
mask, sterile gown and sterile gloves.
Sterile setup for the patient should
begin with adequate skin preparation
with a sterilizing solution (proviodine,
chlorhexidine, etc.) in a large area
surrounding your procedure site.
Place a large sterile sheet on the patient
following this and then isolate the
procedural field with four to six sterile
towels.
This will minimize infective
complications of the procedure.
 Types of central line

Single lumen
Dual lumen
Triple lumen
CONTENTS OF THE TRIPLE LUMEN CENTRAL LINE KIT.
 SELDINGER TECHNIQUE
1. Setup of Equipment and Sterile Preparation
2. Landmarking the Access Site
3. Anesthesia
4. Location of the Vein with a Seeker Needle
[Optional]
5. Placing the Introducer Needle in the Vein
6. Assessment for Venous or Arterial Placement
7. Insertion of the Guide Wire
8. Removal of the Introducer Needle
9. Skin Incision
10. Insertion of the Dilator
11. Placement of the Catheter
12. Removal of the Guide Wire
13. Flushing and Capping of the Lumens
14. Secure the Catheter
ACCESS TO DIFFERENT GREAT VESSELS
Neck - Internal jugular vein
Chest - Subclavian vein or Axillary vein
Groin - Femoral vein
Arm - Peripherally Inserted Central
Catheter(PICC) which include Basilic vein
and Cephalic vein
CATHETERIZATION: INTERNAL JUGULAR
APPROACH
CATHETERIZATION: SUBCLAVIAN APPROACH
 REFERENCE
http://www.rch.org.au/policy/public/Central_
Venous_Access_Device_Management/
http://www.ijccm.org/article.asp?issn=0972-
5229;year=2010;volume=14;issue=4;spage=18
0;epage=184;aulast=Joshi
http://www.icid.salisbury.nhs.uk/ClinicalMana
gement/InfectionControl/Pages/CentralLine.as
px
CENTRAL VENOUS LINE

DINESH A/L KALASILVAN

BMS 13091356
Fluids that can be given through central venous line:

Long-term intravenous antibiotics

Long-term parenteral nutrition, especially in
chronically ill persons
Drugs that are prone to cause phlebitis in
peripheral veins (caustic), such as:
Calcium chloride
Chemotherapy
Hypertonic saline
Potassium chloride (KCl)
Amiodarone
Vasopressors (for example, epinephrine, dopamine)
 Contraindications
Obstructed vein, example clots
Stenosis of the vein
Raised ICP (IJ line)
Severe coagulopathy
Contaminated site
Traumatised site (eg. clavicle fracture)
Burned site
 Complications
Immediate
Pneumothorax
Haemothorax
Arterial puncture
Local haematoma
Air embolism

Early
catheter blockage
Late
Infection : 2.5 infections/ 1000 catheter days
catheter fracture
vascular erosion
vessel stenosis
thrombosis
osteomyelitis of clavicle (subclavian access)
Symptoms of pleura punctuation during Central
Line Placement in conscious patient are:

Coughing
Pain in the chest in site of punctuation
Drop in BP
Dyspnoea
Guidelines for Central Venous Catheter
Care
You must always wash your hands carefully for 15
seconds before and after working with the CVC.
Anyone who helps you with CVC care must do the
same. This is necessary to protect you from
infection.
Use liquid antibacterial soap and paper towels to
dry your hands.
To prevent infection, anything that touches the
exit site of the CVC and anything that goes into
the CVC must be sterile.
 Do not let the CVC exit site get wet until it is well
healed. You may shower 72 hours after the
catheter has been inserted. When you bathe or
shower, you must cover the site with waterproof
material, such as household plastic wrap, taped
over the dressing and injection caps.
Do not submerge the CVC site or caps below the
level of water in a bathtub, hot tub, or swimming
pool.
Store CVC supplies in a clean, dry place such as a
shelf in a closet or a drawer.
Always clean your work area with alcohol and let
it to dry completely before setting up your
supplies. Or you can cover the area with clean
paper towels.
 Use only sterile supplies. Open all packages carefully
without touching the contents. Handle dressings only at the
edges.
Never touch the open end of the CVC when the cap has
been removed.
Never touch the end of the needleless cannula or the end
of the open syringe. If this happens accidentally, use a new
cannula or syringe.
Never use scissors, pins, or sharp objects near the CVC or
other tubing. The catheter could be damaged easily.
If your catheter has a clamp, keep it clamped when not in
use. Some CVCs show where the clamp must be placed. If
your CVC does not show the clamp location, ask your nurse
to show you where to clamp.
Remember to wash your hands thoroughly before and
after working with the CVC.
 Changing the CVC Dressing
The CVC dressing is changed every 7 days if
you are using a transparent dressing.

Change it every 48 hours if you are using

gauze or Telfa island dressing and tape.

If the dressing becomes wet or loose, change

it even if it is not the normal time to change it
 Set up a clean work surface.
Gather supplies and arrange them in the order to be used.
Wash your hands for 15 seconds with liquid antibacterial
soap. Dry your hands thoroughly using paper towels.
If someone else changes your dressing, he or she should
put on sterile gloves.
Carefully loosen and remove the old dressing. Peel the
dressing toward the site without pulling on the CVC. Never
use scissors or sharp objects near the CVC.
Inspect the area around the site for any sign of infection
(redness, swelling, drainage,
tenderness, warmth, or odor). Call the doctor or nurse if
you see any sign of infection. Also report dry skin, rash, or
irritation from the dressing. Note: You may notice some
oozing of blood from the site for several days after CVC
placement. If there is a lot of blood, or if the site keeps
bleeding, call the doctor or nurse right away.
 Check the entire chest area for new or prominent veins, rash,
change in color, or
swelling.
Wash your hands again for 15 seconds with liquid antibacterial
soap. Dry your hands thoroughly with paper towels.
Open the dressing change kit.
Put on sterile gloves.
Activate the ChloraPrep applicator by pinching the plastic wings.
Using the ChloraPrep applicator, vigorously cleanse an area 4 x 5
inches in size. Cleanse for 30 seconds using an up-and-down or
side-to-side motion.
Allow this area to dry for about 30 seconds.
Swab the edges of the cleaned area with the skin protectant swab.
Allow to dry.
Remove backing from the transparent dressing, and place the
dressing over the site. If possible, alternate skin areas where the
dressing is placed to avoid skin irritation.
Loop and tape the catheter to skin to prevent the catheter from
dangling.
Flushing of Catheter With a Clamp
Some CVCs have separate tubes. Each tube is
called a lumen.
Each lumen of the CVC needs to be flushed
regularly to keep it clear of backed-up blood.
You will flush each lumen of the CVC once a
day using 3 cc of heparin solution (100 units
heparin/cc).
 Wash hands for 15 seconds with liquid antibacterial soap. Dry hands
thoroughly with paper towels.
Gather all the supplies.
Wipe the rubber stopper of the medicine vial with an alcohol swab
for 5 seconds.
Remove the syringe cover. Twist on the needleless injection cannula
or needle, if it is not already attached. Remove the cover from the
needleless cannula or needle.
Draw 3 cc of air into the syringe by pulling back on the plunger.
Push the cannula or needle through the rubber stopper of the vial.
Push the syringe plunger to discharge air into the vial.
Turn the vial upside down. Be sure the tip of the cannula or needle
is in the solution. Draw back on the plunger to draw up 3 cc of
heparin into the syringe.
Before removing the cannula or needle from the vial, check for air
bubbles. To remove air bubbles, gently push the heparin back into
the vial and re-measure your dose.
 Remove the cannula or needle from the vial and replace the cap loosely.
Fill other syringes at this time if more than 1 lumen will be flushed.
Replace the needle with needleless cannula, if that is what you are using.
Use the alcohol swab to clean the injection cap of the lumen to be
flushed. Rub the cap with an alcohol swab, rubbing vigorously for 15
seconds, and then allow it to dry. Hold the end of the catheter so it does
not touch anything. Open the clamp on the lumen.
Remove the cap from the cannula or needle and insert into injection cap.
Slowly inject the entire amount of heparin into the lumen of catheter. If
you meet resistance, check to see if the clamp is closed. If there is still
resistance, do not flush that lumen. Call the doctor.
If you are using a standard cap, clamp the catheter as you are finishing the
injection. If you are using a positive pressure cap, remove the syringe and
then clamp the catheter. Then remove the syringe. Place it into the needle
disposal box.
Repeat all of the above steps for each lumen to be flushed, using a clean
syringe to flush each catheter.
Close the syringe disposal box lid and place the container out of reach of
children and pets.
Wash hands for 15 seconds with liquid antibacterial soap.
 Flushing of Groshong Catheter
Groshong catheters are flushed once a week
or when the catheter is used.
The lumens are flushed using 10 cc of saline
solution on the same day of each week.
Heparin is not used because of the special
construction of the Groshong catheter.
 Central venous catheter cap changes

The injection cap on each lumen of your CVC

is changed every 5 to 7 days.

Change a cap any time it is leaking.

 Set up a clean work surface.
Gather all the supplies.
Wash your hands for 15 seconds with liquid
antibacterial soap. Dry your hands thoroughly using
paper towels.
Make sure that the CVC lumens are clamped.
Remove the new cap from its package. Loosen, but do
not remove, the cover on the end of the new cap.
While holding onto the lumen of the CVC with one
hand, use the other hand to:
remove the old cap and set it aside
remove the cover from the new cap
screw the new cap onto the open end of the lumen
Repeat these steps for each of the caps and lumens.
Follow your routine to change caps in the same order
as flushing.
 Central Venous Pressure Monitoring
Central venous pressure is considered a direct
measurement of the blood pressure in the right
atrium and vena cava.
It is acquired by threading a central venous
catheter into any of several large veins.
The pressure monitoring assembly is attached to
the distal port of a multi-lumen central vein
catheter.
To assess right ventricular function and systemic
fluid status.
 Procedure
The CVP can be measured either manually using a
manometer or electronically using a transducer.
In either case the CVP must be zeroed at the
level of the right atrium.
This is usually taken to be the level of the 4th
intercostal space in the mid-axillary line while the
patient is lying supine.
Each measurement of CVP should be taken at this
same zero position.
 Normal CVP is 2-6 mm Hg.

CVP is elevated by :
Over hydration which increases venous return
Heart failure or PA stenosis which limit venous
outflow and lead to venous congestion
Positive pressure breathing, straining

CVP decreases with:

Hypovolemic shock from haemorrhage, fluid shift,
dehydration
Negative pressure breathing which occurs when the
patient demonstrates retractions
 References
http://www.med.uottawa.ca/courses/cvc/Indicati
ons/e_indications.html
http://www.merckmanuals.com/en-
ca/professional/nutritional-disorders/nutritional-
support/total-parenteral-nutrition-tpn
http://www.derangedphysiology.com/main/requi
red-reading/equipment-and-
procedures/Chapter%202.1.4/indications-
contraindications-and-complications-cvc-
insertion
Arterial Blood Gas

CHUA XIAO SHUANG

BMS 13091258
 Arterial Blood Gas (ABG)
Measures the acidity (pH) and the levels of
oxygen and carbon dioxide in the blood from
an artery.
 Which artery is normally used?
ABG sampling is usually performed on the
radial artery because the superficial anatomic
presentation of this vessel makes it easily
accessible.
In cases where distal perfusion is
compromised and distal pulses are
diminished, femoral or brachial artery
puncture can be performed instead.
 Indications
Any unexpected deterioration in an ill patient.
Anyone with an acute exacerbation of a chronic
chest condition.
Anyone with impaired consciousness or impaired
respiratory effort.
Signs of CO2 retension, eg bounding pulse,
drowsy, flapping tremor, headache.
Cyanosis, confusion, visual hallucinations.
To validate measurements from trancutaneous
pulse oximetry.
 Relative
Contraindication Contraindication
An abnormal modified Severe coagulopathy
Allen test Anticoagulation therapy
Local infection or distorted Use of thrombolytic agents
anatomy at the potential
puncture site
The presence of
arteriovenous fistulas or
vascular grafts
Known or suspected
severe peripheral vascular
disease of the limb
involved
 How to take an ABG?
If you are on oxygen therapy, the oxygen may be
turned off for 20 minutes before the blood test.

1. Wash your hands, introduce yourself to the

patient and clarify their identity. Explain what
you would like to do and obtain consent.
2. Gather the necessary equipment.
3. Position the patients arm with the wrist
extended.
 How to take an ABG?
4. Locate the radial artery
with your index and
middle fingers. Perform
Allens test where you
compress both the radial
and ulnar arteries at the
same time. The hand
should become white,
release the ulnar artery
and the colour should
return to the hand.
 How to take an ABG?
5. Put on your gloves and attach
the needle to the heparinised
syringe. Flush the heparin
through the syringe and again
locate the radial artery using
your non-dominant hand.
6. Insert the needle at 30
degrees to the skin at the point
of maximum pulsation of the
radial artery. Advance the needle
until arterial blood flushes into
the syringe.
 How to take an ABG?
7. Remove the needle/syringe and press firmly
over the puncture site with the gauze to halt the
bleeding. Remain pressed for 5 minutes.
8. Remove the needle and discard safely in the
sharps bin.
9. Cap the syringe, push out any air within it,
and send immediately for analysis. Remove your
gloves and dispose them in the clinical waste
bin. Wash your hands and thank the patient.
How to take an ABG?
ABG Normal Values
ABG Analysis
ABG Analysis
ABG Analysis
 References
Oxford Handbook of Clinical Medicine 10th
Edition
https://www.nps.org.au/australian-
prescriber/articles/the-interpretation-of-
arterial-blood-gases
http://www.webmd.com/lung/arterial-blood-
gases#1