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59 Cards in this Set
- Front
- Back
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Indwelling Catheter Flushing
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Use SAS Flushing Method for these catheters (CLC2000 caps)
- Saline: Check for blood return and inject 5ml of normal saline - Add: medication or IV contrast - Saline: Flush with 5ml of normal saline - After flushing, always withdraw syringe BEFORE clamping the line. |
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Non-CLC 2000 cap Catheter Flushing
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When you have a catheter without a CLC2000 cap you use the SASH Flushing Method:
- SAS portion is the same but 'H' at the end stands for heparinized saline. Flush with heparinized saline after the last normal saline flush. |
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Types of Heparinized Saline Doses
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There are 2 doses of heparinized saline to use:
- 5ml of 10 units heparin per ml of normal saline (Blue tip syringe) - 5ml of 100 units heparin per ml of normal saline (yellow tip syringe) A white tip syringe is normal saline without any heparin. |
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Which Catheter cap does not require heparinized solution when flushing?
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The CLC 2000 Catheter caps because they create a process where no backflow can occur so there is no heparin needed because there is no chance of blood in catheter.
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Purpose of flushing a Catheter
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Catheters are flushed to prevent clotting of blood in the catheter and to clean out any previous injection material.
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Purpose of a Guidewire
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Guidewires allow the safe introduction of the catheter into the vessel. Once the catheter is in place, the guidewire allow the rad to position the catheter withine the vascular network.
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Two Main Types of Guidewire Tips
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Straight and Curved (J-tip)
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Length of Guidewires
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Conventional guidewires are about 145cm long. This is because the catheters overlaying the guidewires are usually about 100cm long. It is important that the guidewire be much longer so there is no chance of losing it.
- Guidewire length can range from 45-260cm and they are usually more than twice the normal catheter length. Should be AT LEAST a minumum of 10cm longer than the catheter, but are usually much more. |
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Guidewire Size
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A guidewire must fit snugly so there is no backflow through the catheter.
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Different types of Needles for Guidewire Insertion
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There are three typical arterial needle designs:
1. One piece or single wall 2. Two piece or double wall 3. Three piece or sheath |
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One Piece or Single Wall Needles
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Needle is beveled and is without a stylet.
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Two Piece or Double Wall Needles
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Needle has an outer cannula with an inner stylet and an obturator.
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Three Piece or Sheath Needles
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Contain a cannula, stylet, and sheath.
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The Obturator or Stylet
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A solid rod with a metal hub which is ground or "fitted" to match the bevel of the needle. They are introduced with the needle in order to prevent cutting a tissue plug and clogging the needle.
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Obturator Design
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Obturators can have regular bevels (blunt) or trocar (sharp) points. Which type of obturator it is will depend on the size and type of vessel being accessed.
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Specific Needle Types
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- Angiocath
- Amplatz - Potts-Cournand - Seldinger - Butterfly - Chiba |
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Angiocath Needle
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3 piece needle with a beveled metal cannula and a Teflon sheath. Used for cubital vein puncture.
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Amplatz Needle
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3 piece needle with a beveled cannula, stylet, and fitted radiopaque Teflon outer sheath. Comes in 16, 18, and 20 guage sizes. Used for femoral, brachial, and axillary artery puncture.
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Chiba Needles (PTCA needle)
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1 piece needle. Long, thin needles that are available in 22 and 23 guage sizes. Has no obturator or sheath. Used for percutaneous biopsy and aspiration.
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Potts-Cournand Needle
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3 piece needle with a beveled outer cannula and a hollow, beveled stylet and a blunt obturator. Available in 18 guage size. Used for arterial and venous puncture.
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Seldinger Needle
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2 piece needle with a thin-walled outer cannula with an inner stylet that can be beveled, diamond shaped, or pointed. Available in 16, 18, and 20 guage. Used for arterial and venous puncture.
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Butterfly Needle
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1 piece needle that is available in various gauges. They have small "wings" or "ears" attached to the hub portion of the needle to help when entering the vessel. Used to enter smaller veins.
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Stubbs Needle Gauge System
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Relates needle size to a whole number. The Stubbs number represents the outside diameter of the needle. This means that the larger the Stubbs number, the smaller the outside diameter since it is in relation to a whole number. Stubbs Gauge range is 7 (largest) to 33 (smallest).
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Dilator
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A thick walled plastic tubing with a tapered end. The end is small and then dilates to a larger end. They are used to gently widen a vessel so a catheter can be introduced safely with less chance of perforation.
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Sheath
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A small catheter that stays in during the whole procedures so that other catheters can be introduced through it. Once a sheath has been placed, controlled access of the vasculatures is assured and the chance of vessel trauma is reduced by limiting the numerous catheter passages through the vessel itself. Often used in angiographic procedures that require multiple catheters be used.
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5 Major Injection Sites
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- Femoral Artery
- Axiallary - Brachial - Aorta (Translumbar) - Direct Puncture (Carotid) |
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Femoral Injection Site
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Most desirable because:
- it can be used to evaluate multiple organs - it is a remote site to puncture - it is less trauma and sedation to the patient - it has a low complication rate - it is a large vessel over the femoral head so you can put pressure over it after procedure SHOULD be accesses below the inguinal ligament. |
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Axillary/Brachial Injection Site
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If using these:
- the left is preferred because it has the best route to access the arteries because there are no "turns" as there are in the right These are used if the femoral arteries are not accessible or if there is aortic occlusion. Problems include: - Smaller vessels - Greater patient discomfort due to the fact that they must be strapped on an arm board for two hours - Has 2X the complication rate as compared to femoral access |
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Aorta (Translumbar) Injection Site
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Performed when there is suspected aneurysm or occlusion of the aorta or when neither femoral or brachial arteries are available. Injection takes place 1 hand breadth to the left of the spinous process and below the level of the 12th rib. There can be NO catheter changes with this approach and it is undesirable due to the danger of retroperitoneal hemorrhage due to the inability to put pressure on it after procedure.
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Direct Puncture
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Least used! Carotid, Renal, etc...This is very rare and only done if necessary because you have to cut all of the tissue above and then after the procedure, the vasculature and tissue all has to be repaired. Highest chance of complication.
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Seldinger Technique of Vessel Puncture
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1. Patient Prepped
2. Put in needle to center of artery (actually, seldinger is a double wall puncture and then pull back until in the center of vessel...modified seldinger is a single wall puncture directly into center of vein) 3. Put in guidewire 4. Pull needle out 5. Wipe the guidewire off and feed the dilator over the wire 6. Once dilated, pull dilator off 7. Put on sheath if you are using one 8. Feed catheter over guidewire inside sheath or directly if no sheath is being used 9. Pull the guidewire out, hook up to pressure injector, and do procedure. (SEE page. 134 of Snopek book) |
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Patient Preparation for Angiography
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A complete preexam history and consultation should be done with the patient. Patients should be educated on the risks and complications of the procedure and need to sign an informed consent. Potential complications include vasovagal reaction, stroke, heart attack, death, bleeding, nerve, blood, or tissue damage, and allergic reaction.
Before the procedure, patients should not have solid foods and should hydrate well up until 2 hours before the exam. All blood work (BUN, PT and INR)and pulses should be checked before proceding with the exam. Last, make patients as calm and comfortable as possible. |
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Patient monitoring during the procedure
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During the procedure, physiologic monitoring of the patient is essential. This involves the measurement of blood pressure, renal output (if needed), heart rate and rhythm (ECG), respiration, pulse oximetry, and pharmacologic monitoring.
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Informed Consent
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Includes:
- Disclosure of risks involved with the procedure - understanding by the patient - authorization or voluntary permission to perform the procedure - competence of the patient to negotiate the document |
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Postprocedural Monitoring and Care of the Patient
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First, manual pressure is applied to the puncture site once the catheter is removed. Once bleeding is stopped, the patient is moved to recovery and remains on bed rest for a minimum of 4 hours during which there is continuous monitoring of the patient pulse and vital signs as well as the puncture site. Patient is also encouraged to drink fluids and must have someone to care for them for 24 hours after being discharged.
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Central Venous Catheters
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For frequent and continuous injections of medications or fluids for nutritional support such as:
- chemotherapy - long term antibiotic/pain control/IV nutrition - frequent blood draws - dialysis - plasmapheresis |
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Central Venous Catheter types
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1. Short term (less than 1 week)
2. Mid term (1-8 weeks) 3. Long term (greater than 3 months) |
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Short Term CVC Types
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- Standard Needle
- Saline/Heplock - Triple Lumen Central Catheter - Quinton Catheter |
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Standard Needle
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This is the standard IV - Peripheral
- Single needle in cephalic, medial, radial, or palmar arch veins - Port is placed at end of needle - injection is continuous with no barrier to backwash |
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Hep/Saline Lock CVC's
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Goes in the arm with a one way valve - Peripheral
- For intermittent therapy - Flushed before and after use (see SAS flushing cards) |
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Triple Lumen CVC's
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Inserted by Surgeons and Rads verify
- Insertion into subclavian or internal jugular and goes to right atrium. Measures central venous pressure. NO CONTRAST in these! |
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Swan-Ganz Catheters
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Quadruple lumen catheter into the subclavian or internal jugular. Goes to the pulmonary artery to measure pressures. NO CONTRAST in these! The 4 ports go into the right atria (measures CVP), pulmonary artery (measures sytolic and diastolic), and pulmonary capillaries.
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Quinton Catheters
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WE DON'T TOUCH THESE!
- Used after high dose chemo for hemodialysis. Can stay in a max of 1 week due to infection. Go into the right jugular or subclavian and is a double lumen for intake and venous return. May be temporary or tunneled...never flush or unclamp! |
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Midterm Central Venous Catheter Types
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1. Midline Catheter
2. Midclavicular Catheter 3. PICC Line |
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Midterm IV Catheter Facts
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Midterm IV catheters damage veins so they are only placed once. There are 4 placement sites used: Right and left basilic veins or right and left cephalic veins.
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Midline Catheters
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3-4 Frech single lumen catheters used for short term (less than 2 weeks) IV antibiotic therapy. These are like an IV, but are placed further in for greater stability than a short-term IV.
They are placed in the median cubital vein and advanced to the basilic artery just shy of the shoulder. |
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PICC Lines
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Peripherally Inserted Central Lines (the longer version of a midline catheter).
Still placed in the median cubital vein, but they end in the SVC. Is a 4-5 French double lumen catheter for total perenteral nutrition. Can be single lumen for greater than 2 week antibiotic therapy. Length is dependant on patient size...they measure and cut these. |
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PICC Line PROS
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- Only slightly more invasive than a standard IV
- Easily inserted and removed - Inexpensive - Complications are rare and usually minor |
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PICC Line CONS
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- High maintenance (require daily flushing)
- Often migrates - Limits lifestyle - Best suited for treatments lasting several weeks to 6 months |
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Power PICC Lines
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The clamp will state the maximum injection rate (flow rate) and the other side will remind the user to check for blood returen before using and the flush. The tubing will have printed on it "power injectible"
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Risks of PICC lines
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- bleeding around site into chest
- air emboli - abnormal heart rhythm - brachial plexus injury - DVT - Infection |
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Long Term CVC's
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Long term IV access catheters are tunneled under the skin and end at the SVC. The body of these catheters contains a bicuff that causes scar formation acting as a barrier to prevent bacteria migration from skin up the catheter body to the blood stream. Types are:
- Hickman - Groshong - IVAD - Hahn - Plasmapheresis Catheter |
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Hickman Catheters
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Must be surgically placed.
- 4-5 French single or double lumen catheter made of silicone - Inserted into chest wall (tunneled) via the subclavian vein to the SVC - Has an antibiotic impregnated cuff - Is good for use as long as it is patent and/or uninfected (BROVIAC catheter isthe smaller lumen size of a hickman for peds) |
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Groshong Catheter
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Must be placed surgically.
- Is similar to Hickman but does not have an open-ended tip. - Has a valve tip so there is no blood backflow (old coin purse) - Can open inward for blood draw - Used for patients with low platelet counts - Good as long as it is patent and uninfected * Since there is no backflow, there is no need to flush these with heparin. |
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IVAD Devices
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Implantable Venous Access Devices - must be surgically placed
- Portacath is the most widely used - Metal/plastic chamber with a resealable synthetic port and drainage line. - Administer through skin and rubber septum - Must be flushed daily but no skin care is needed - Can be permacath (longer and more durable) or passport (placed in arm instead of chest) |
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Access to IVAD Devices
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Accessed using Huber Needles - Non-coring needles that are at a 90° angle to the tubing.
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What you must have to use a Power Injectable IVAD Port
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One of the following:
1. Port ID Card 2. Dictated medical record that the port is power injectable. Bracelets and pendants are not acceptable means of identification for power inectable ports. |
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Hahn Catheters
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Long term access catheter with multiple ports. It is like a Hickman, but is shorter and does not require surgical placement.
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Plasmapheresis Catheters
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12 French catheter for bone marrow transplant. Use to harvest, give chemo, and do marrow replacement
- Autoimmunotherapy treatment - Good for as long as it is patent and not infected. |
