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34 Cards in this Set

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PIV’s – Improving Your Success
Calm/Confident
Gravity & Position
Stabilize/Approach
Move blood where you want it
NTG paste?
Local anestheticCalm/Confident
Gravity & Position
Stabilize/Approach
Move blood where you want it
NTG paste?
Local anesthetic
Finger Tourniquet
Loose skin
Difficult to advance
Fail – explanation?
Know when to quit
Know your “pinch-hitter”
PIV’s – Potential Complications [6]
Bruising
Pain
Phlebitis
Infection
Nerve damage
Extravasations
Arterial Lines: indications [8]
Pressor agents being infused
Multiple ABG’s required
CPP monitoring for MAP
Cardiovascular compromise

BP changes may be rapid
NIBP may be unreliable
Direct manipulation of CV system
Deliberate hypotension
Radial artery site
Preferred site; superficial, accessible, compressible, and the site is easy to clean and maintain
Collateral circulation
Small size limits success of cannulation
Dorsalis pedis artery site
Unpopular because of the distortion produced in the pulse waveform at the site.
Allen’s Test
Evaluates collateral flow to the hand when the radial artery is occluded
Occlude the radial and ulnar arteries with the thumb and forefinger of each hand
Elevate the arm above the head, and have the patient open and close the hand until the fingers turn white
Release the ulnar artery, and determine the time it takes for normal color to return to the fingers
Normal response time is 7 seconds.
Abnormal collateral flow is 14 or > seconds.
art line Equipment and Insertion Technique [9]
Hyperextend wrist to bring the artery closer to the surface
Wear gloves
Prep skin
Localize with lidocaine
20 g. over the needle catheter, 2 inch cath.
Hold the needle like a pencil and insert it at a 30 degree angle to the skin surface
Technique: through and through/normal iv style
If using an arterial line kit with wire, the wire should freely advance
Check wave form and blood return prior to suturing catheter in place (you won’t usually need to suture it)
Parts to an Arterial Pressure Line
Start with a bag of heparinized saline: 2units of heparin per cc. The bag is connected to a standard transducer setup: soft tubing from the bag to the transducer, and stiff tubing from the transducer to the patient.

The bag of flush is pumped up to 300mm of pressure with a pump bag – the transducer controls the forward flow of flush into the artery, keeping it open, at a rate of 3cc per hour. If the line weren’t pressurized this way, the arterial pressure would make the patient’s blood climb right back up the line.
art line Potential Complications [5]
Hematoma
Nerve damage
Arterial occlusions: 25% incidence, 3% permanent occlusion
Ischemic necrosis of digits: rare
Catheter related septicemia: 1-2% of insertions
Anacrotic limb (QRS waveform)
Anacrotic limb (QRS waveform)
Rate of rapid rise reflects the blood ejected from the LV through the aortic valve.
IN GENERAL the upstroke reflect contractility and SVR. Will be faster if contractility is increased or SVR is decreased. Conversely, upstroke will be slower if contractility is decreased or SVR is increased.
Dicrotic limb (T wave to dicrotic notch)
Downward slope that begins at the end of anacrotic limb and slowly goes back to baseline.

The decreased blood pressure and blood flow to the periphery represents this portion of waveform.
Dicrotic notch
Dicrotic notch

Aortic valve closed with onset of diastole and coronary perfusion

Occurs at end of T wave
Arterial Waveform Considerations- Why does it look so funny?
Inaccurate calibration

Air in line

Catheter kinked

Hypotension


Transducer level

Stop-cock turned off

Low inflation of pressure bag
Indications for CVP during surgery [8]
Lack of peripheral veins/inability to cannulate peripheral veins
Infusion of irritating substances
Delivery of potent drugs such as catecholamine's
Avoidance of medication interruptions
Delivery of incompatible medications in a multi-lumen catheter
Aspiration of air emboli
Central venous access for monitoring (CVP/PAP) or transvenous cardiac pacing
Blood sampling
Contraindications central lines [4]
No absolute contraindications
Avoid sites of sepsis
Carotid artery aneurysm precludes using internal jugular vein on same side
Reconsider central venous cannulation in hypocoagulation and hypercoagulation states or if septicemia is present
most common central line site
IJ
Complications central lines
Pneumothorax Hemothorax
Infection Arterial puncture
Hematoma Venous thrombosis
Air embolism (reduced with head down position)
Catheter embolus Catheter malposition
Thoracic duct obstruction or injury (reduced with right side insertion)
Pleural effusion Nerve injury
Pericardial effusion Cardiac arrhythmias
Myocardial perforation and tamponade
CVP Waveform A wave
Due to atrial contraction, absent in A-fibb, exaggerated in junctional rhythms
Occurs at end diastole
CVP Waveform C wave
Due to tricuspid valve elevation (toward atrium) during early ventricular contraction (systole)
CVP Waveform V wave
Reflects venous return against a closed tricuspid valve
Systolic filling of atrium
No cvp a-wave if in ____?
afib
CVP measurement – How to use it
Assess right atrial pressure – should equal CVP and RVEDP

High pressure = high volume – RV failure?
Low pressure is generally d/t hypovolemia

RVEDP is 1/2 LVEDP in healthy heart
Equipment for CVP insertion
Skin prep, sterile gloves,
towel drapes
Local anesthetic with
25 g. 3 ml syringe
Needle, guidewire, scalpel, dilator, catheter
Suture, Monitor setup, sterile dressing supplies
Preparation for CVPinsertion
Consent in compliance with institution policy, unless emergent
Position patient head down, if possible
Select appropriate vessel and approach. If you are unable to place a chest tube, or do not have immediate backup, avoid the subclavian route and possibly IJ
Sterile prep
Anesthesia/Sedation
Mechanics CVP insertion
Using finder needle, aspirate venous blood
Using larger needle or needle-catheter system, aspirate venous blood
Determine oxygen tension
Attach an arterial blood sample syringe to the needle hub and aspirate venous blood
Once aspirate, insert guidewire, remove needle and attach hemostat to proximal end of wire
Process arterial blood syringe sample to establish that it is venous blood
cvp site confirmation
Transduce pressure at hub site
Connect to transducer and record pressure, assess waveform

After confirmation of venous blood proceed with dilation of tract and vessel and insertion of triple lumen catheter or introducer

Assess blood return from all ports prior to suturing, place occlusive dressing, chest x-ray
Indications for PA catheter
Cardiac surgery
Heart, lung, or liver transplant surgery
Poor LV function, low EF, pulmonary HTN, sepsis, toxemia
Surgery involving x-clamping aorta?
Contraindications for PA catheter
No absolute contraindications
Relative contraindications:
Coagulpathies
Significant thrombocytopenia
Prosthetic right heart valve
Endocardial pacemaker leads
Infection at insertion site
Potential Complications PA CATH
Carotid artery injury (1.9%)
Pneumothorax (0.5%)
Cardiac rhythm disturbance (over 70%)
Pulmonary artery rupture (0.064%)
Pulmonary infarction
Sepsis (risk is 0.3-0.5%/day)
PA waveform/pressure tracing
Right atrium
(1-8 mmHg)
Low amplitude
A-wave atrial contraction
C-wave ventricular contraction
PA waveform/pressure tracing
Right ventricle
(15-25/1-8 mmHg)
Upstroke 2-3x larger
No diacrotic notch
PA waveform/pressure tracing
Pulmonary artery
(15-25/8-15 mmHg)
Generally smaller than RV
Presence of diacrotic notch
PA waveform/pressure tracing

Pulmonary artery occlusive pressure
(6-12 mmHg)
Measures “back pressure” from pulmonary veins
Low amplitude waveform
Increase in pressure seen with volume overload, LV failure, Mitral stenosis, tamponade
PA Catheter distances
InsertSite ToRA ToRV ToPA
Rt. IJ 20 30 45
Lt. IJ 25 35 50
Subclavian 15 25 40
Rt AC 40 50 65
Lt AC 45 55 70
Femoral 30 40 55