Tips on Central Venous Catheter & Pulmonary Artery Catheter.

Tips on CVC & PA Catheter
DR. SHERIF BADRAWY

The size of vascular catheters
1a
Dr.
Sherif
Badrawy
Digitally signed by Dr.
Sherif Badrawy
DN: cn=Dr. Sherif
Badrawy, o=KKUH,
ou=Critical Care,
email=sherif_badrawy@
yahoo.com, c=SA
Date: 2015.04.10
00:00:56 +03'00'

☆ French size is a series of whole numbers that
increases in increments of roughly 0.33 mm
(e.g., 1 French = 033 mm, 2 French = 0.66 mm).
☆ The gauge size (originally developed for solid
wires)
has no definable relationship to other units of
measurement and requires a table of reference
values
1b

interpretation of ScvO2
some catheters (eg Edwards PreSep
oximetry catheters) are capable of
measuring ScvO2 continuously
- ScvO2 is usually in the order of 4-5%
higher than mixed venous (SvO2)
4a

The length of venous segments involved
in the insertion of
PICCs and CVC
5a

anatomy of the femoral triangle.
6a

(1) IV access (especially if difficult peripheral access)
(2) CVP monitoring
(3) ScvO2 monitoring/sampling
(4) Infusions of irritant substances (e.g. vasoactive
agents, chemotherapy , TPN or K)
(5) Renal replacement therapy, plasmapheresis and
apheresis
(6) Transvenous pacing
7b

☆ coagulopathy
☆ respiratory failure
☆ ↑ICP (cannot tilt head down)
➜ can use femoral approach in all the situations above
☆ obstructed vein (e.g. thrombus, or tumour)
☆ overlying skin infection, burn or other disease process
☆ hemorrhage from target vessel
☆ uncooperative patient
8b

Which port is used for CVP monitoring ?
9a

brown lumen is the distal lumen (used
for CVP monitoring)
9b

bleeding (check coagulation), loss of guide-wire,
air embolism (Rx é left lateral trendelenburg
position, 100% O2, tighten connections &
attempt to aspirate air), dysrhythmias, damage
to structures (pneumothorax, haemothorax,
chylothorax), nerve injury, arterial puncture,
bleeding, infection, thrombosis
10b

☆ ultrasound visualisation of needle insertion,
guidewire placement and CVC
☆ pressure measurement
☆ assess for CVP trace
☆ inject agitated saline and observe rapid
appearance of bubbles on bedside echo
☆ CXR ➜ run parallel to the shadow of the SVC, and
the tip of the catheter at or slightly above the third
anterior intercostal space.
11b

Handy tips on CVC insertion
12a

☆ Do not shave hair at insertion site unless it interferes with dressing adhesive,
as it may ↑risk of infection from disruption of the epidermal barrier by skin
lacerations.
☆ Draw up normal saline in a 10-mL syringe and lignocaine in a 5-mL syringe
to ensure these two agents are not mixed
☆ Use ECG monitoring during insertion to detect transient dysrhythmia caused
by guidewire
☆ Do not routinely replace CVC to prevent infection
☆ Remove any intravascular catheter as soon as it is no longer required
☆ CVC insertion is not necessary, or even optimal, for fluid resuscitation. A
short wide-bore cannula is better.
☆ Ultrasound guidance is virtually the standard of care
12b

pathology affects accuracy of CVP as a
measure of preload
13a

anything affecting compliance of central
compartment:
◒ Cardiac: Tricuspid, pulmonary & mitral valve
disease, right heart failure, tamponade,
restrictive pericarditis
◒ Respiratory: changes in intrathoracic
pressure, any cause of ↑pulmonary vascular
resistance
13b

Catheter-related bloodstream infection
(CRBSI)
14a

◒ bloodstream infection attributed to an
intravascular catheter by quantitative
culture of the catheter tip
◒ this definition is primarily used in
research
14b

Central Line Associated Blood Stream
Infection (CLABSI)
15a

◒ a lab-confirmed bloodstream infection in a pt
who had a central line within the 48 hour period
before the BSI, and
not related to an infection at another site
◒ used in non-research/ clinical settings
◒ confirmation of CLABSI requires both a
positive blood culture AND a collaborative
clinical and microbiological review
15b

◒ subclavian generally preferred
◒ higher rates of CLABSI with internal jugular access in
tracheostomy patients
◒ some studies suggest greater colonisation and infection of
central lines at the femoral site followed by the jugular
◒ femoral access may have higher rates of CLABSI in
patients with a high BMI
◒ recent meta-analysis found that femoral access did not
have higher rates of CLABSI
16b

Routes of Infection of CVC
17a

◒ internal lumen of catheters through break points in the infusion system, ex
stopcocks and catheter hubs
◒ along outer surface of the catheter in the tract created during insertion
◒ Microbes in blood can attach to the IV portion of catheter. ➜ proliferate ➜
septicemia. 17b

✬ Recognised pathogens include:
◒ Staphylococci (S. aureus, coagulase
negatives)
◒ Gram negative bacteria (e.g. E. coli,
Pseudomonas spp, Klebsiella spp)
◒ Enterococcus spp
◒ Candida spp
18b

Number of CLABSI x 1000/ Number of
central line days
19b

ANZICS Guideline 2012:
Insertion site -
20a

▧ SVC preferred, then IJ then femoral
20b

ANZICS Guideline 2012
Central line selection -
21a

▧ minimise number of lumens,
▧ lipid-containing fluids require dedicated lumes,
▧ some patients should have antibiotic coated CVLs
(chlorhexidine and silver sulphadiazine coated lines
(not silver-only or rifampicin and minocycline lines):
high CLABSI rate despite prevntion protocol
compliance, >7day duration, immunocompromise or
burns)
21b

Preparation -
22a

▧ dedicated trolley and packs
▧ Aseptic technique and maximal barrier
precautions (clip hair do not shave, ≥0.5%
chlorhexidine in 70% alcohol preferred but if
contraindicated use 5% povidone iodine in
alcohol, cover whole patient with drapes, stop if
sterility is compromised, handle ends of
administration sets with gauze soaked in
chlorhexidine)
22b

Central line review -
23a

▧ performed daily, look for: signs of local
infection at the insertion site
(tenderness, pain, redness, swelling),
signs of systemic infection, suture and
dressing integrity, catheter position,
patency of lumens and ongoing need -
remove as soon as possible
23b

Central line replacement -
24a

▧ replace in <24 hours if suspicion of
suboptimal sterility (e.g. emergency insertion),
▧ avoid rewiring (consider if: risks outweighed
e.g. burns, coagulopathy, <72h since CVL
inserted, and no evidence of CLABSI)
▧ remove witihn 24 if lumen blocked, new
venipuncture site is necessary. If over a
guidewire ➜ can create PE.
24b

Replacing Central Venous Catheters
25a

☸ Septicemia from CVC begins to appear
after catheters is in place for 3 days
☸ NO ROUTINE REPLACEMENT [does
not reduce the incidence of catheter-
related infections].
☸ routine replacement ↑catheter related
mechanical complications
25b

Indications for CVC Replacement
26a

☸ purulent discharge from the catheter insertion site.
Erythema around the catheter insertion site is not absolute
evidence of infection & is not an indication for catheter
replacement.
☸ If the catheter is suspected as a source of sepsis and the pt
has a prosthetic valve, immunocompromised, or has severe
sepsis or septic shock.
☸ catheter has been placed emergency, without strict
aseptic technique ➜ replace within 24h
26b

Replacing Peripheral Venous Catheter
27a

☸ To avoid inflammation (phlebitis), not
infection
☸ replacement of peripheral vein
catheters (using a new venipuncture site)
is recommended every 72 to 96 hours.
27b

☸ Thrombosis is the most common cause
☸ Insoluble precipitates in the infusatc
can accumulate in
the catheter lumen ➜ Obstruction
28b

Subclavian Vein Thrombosis dt CVC
29a

☸ 1% of pts with subclavian vein catheters
☸ The hallmark of subclavian vein thrombosis is
unilateral
arm swelling
☸ thrombus can extend proximally into the SVC, but
complete SVC occlusion & SVC syndrome is rare
☸ Symptomatic PE can occur
☸ immediate catheter removal + elevation of the
affected arm + Rx heparin anticoagulation
29b

☸ venous ultrasound has a high (> 90%)
sensitivity and specificity for the
detection of proximal deep vein
thrombosis in the leg.
☸ Rx immediate catheter removal &
heparin anticoagulation
30b

Securement devices -
31a

fix adequately to prevent movement,
suture-less securement devices (unclear
benefit in CVLs, reduce CLABSI in PICC
lines)
31b

Dressings -
32a

▧ Sterile, transparent semipermeable dressings
allow visualisation of the insertion site, and an
additional anchor if properly maintained.
▧ Use sterile gauze if bloody or wet, changes
dressings
regularly (7 days for standard dressings, 2 days
for gauze)
32b

Central line maintenance -
33a

hand hygiene and swab hub, use
chlorhex swabs
33b

Adhesive, Semipermeable Dressings for
catheter care
34a

☸ transparent, semipermeable create a moist
environment that is beneficial for wound healing
☸ popular but do not reduce the incidence of
catheter colonization or infection when compared to
sterile gauze dressings
☸ can increase the risk of infection dt moist
environment favors the growth of microorganisms.
☸ apply for skin sites that are close to a source of
infectious secretions (e.g., a Tracheostomy).
34b

☸ does not reduce the incidence of
catheter-related infections
☸ can promote Atibiotic-resistance
☸ routine use of antimicrobial ointments
is not recommended
35b

☸ to prevent thrombotic occlusion.
☸ heparin lock [Catheter filled with heparinized
saline and capped when idle]
☸ Arterial catheters ➜ continuous flush by a pressure
bag
☸ saline alone is as effective as heparinized saline in
venous Catheters
☸ sodium citrate is as effective as heparinized saline
in Arterial Catheters
36b

initial management of suspected
catheter-related septicemia ➜ Isolated
Fever
37a

catheter-related septicemia ➜ Severe
sepsis or septic shock
38a

catheter-related septicemia ➜
Neutropenia
39a

catheter-related septicemia ➜ Prosthetic
Valve
40a

Treatment of Catheter-Related
Septicemia
41a

♚ Catheter Removal
◒ should be removed if cultures confirm the
presence of catheter related septicemia.
◒ not always necessary if the pt shows a
favorable response to empiric antibiotics and the
responsible organism is Staph. epidermidis
◒ If not easily replaced can sometimes be Rx
with antibiotic lock Rx
41b

When a catheter is not used for continuous IV
infusions, a concentrated antibiotic solution
(usually 1 to 5 mg/mL) can be injected into the
lumen of an infected catheter and left in place for
hours to days ➜ best for tunneled catheters in
place > 2 weeks as an intraluminal source of
infection ➜ Unsuccessful with Candida
42b

Duration of Therapy of Catheter-Related
Septicemia
43a

uncomplicated cases ➜ 10 to 14 days of
antibiotics
{only 5 to 7 days for most cases of Staph
epidermidis}
43b

Persistant Sepsis [Continued signs of
sepsis after a few days of antibiotic]
44a

♚ Suppuratsve Thrombosis [Infected thrombus surrounding the catheter tip]
◒ Purulent drainage from the catheter insertion site is
not always present
◒ Catheter removal is essential
◒ surgical incision and drainage is recommended
♚ Endocarditis
◒ Vascular catheters are MCC of nosocomial endocarditis
◒ Staph. aureus is the MC organism
◒ TEE is diagnostic procedure of choice for endocarditis.
◒ Documented Endocarditis ➜ catheter removal is
mandatory & Antibiotics for 4 to 6 weeks
♚ Disseminated Candidiasis
◒ Dx missed in > 50%
◒ cultures are often negative
◒ Heavy colonization of the urine in high-risk patients ➜ empiric antifungal Rx
44b

Value Pulmonary Artery Catheter
45a

◒ Swan-Ganz catheter (or 'the yellow
snake')
◒ Gives information about pressure not
volume
45b

Problems é interpretation of PAC
46a

◒ Error of at least 10% in measuring CO,
even é fastidious attention to technical
detail
◒ Variable relationship between pressure
& volume
◒ Inaccurate measures if valvular disease
or intra-cardiac or intra-pulmonary shunts
46b

☆ Optimising preload using measurement of stroke volume
& cardiac index
☆ Differentiating types of shock
☆ Differentiating cardiogenic from non-cardiogenic
pulmonary oedema
☆ Guiding the use of vasoactive drugs, fluids & diuretics,
especially ῳ HD instability & ↑lung water, RV or LV
dysfunction, or pulmonary hypertension
☆ PA catheter can guide afterload-reducing therapies
(inhaled prostacyclin or NO) in ARDS
47b

Measures provided by a PAC:
48a

◒ RV Pressure: Normal systolic 15 - 25 mmHg, diastolic 0 - 8
mmHg
◒ PA Pressure: Normal systolic 15 - 25 mmHg/Diastolic 8 -
25 mmHg/ mean PAP 10 - 20 mmHg
◒ PAOP (LA pressure via wedging): Normal 10 - 20 mmHg
◒ True mixed venous saturations - either continuous or
intermittent
◒ Measurement of cardiac output via thermodilution -
either continuous or intermittent
◒ Also can monitor core temperature
48b

Settings it is commonly used are:
49a

☆ right ventricular failure
☆ pulmonary hypertension
☆ weaning failure of cardiac origin
☆ post-cardiac surgery
49b

☆ preferred site: RIJ > LSCV > RSCV > LIJ (can also insert femorally) insert
sheath (aka Cordis) first
transducer is attached to the distal lumen to observe distinct waveform
☆ once the right ventricular waveform is seen the balloon is inflated to allow
the PAC to progress through the right heart
☆ distinct waveforms plus known distance inserted aid certainty about position
☆ If these transitions do not occur at the estimated length then the catheter
should be withdrawn & reinserted
☆ Once the pulmonary artery is reached the wedge waveform can be used to
confirm position PAC is secured é the balloon deflated
51b

Chest x-ray - the tip should curve, éout
loops or knots, into a main pulmonary
artery but not be > peripheral than the
junction bw the medial & middle third of
the ipsilateral lung field in West zone 3
(below the level of the left atrium)
52b

◒ Air embolism
◒ Dysrhythmia. For sustained VT remove PAC from RV. For
VF remove PAC & defibrillate
◒ RBBB: avoid use in LBBB otherwise risk of CHB (➜ pacing)
◒ Catheter knotting/kinking: do not advance against resistance
◒ Valve damage: avoid by inflating for forward passage &
deflating for retraction
◒ PA rupture from balloon inflation. May present é
haemoptysis & infiltrate around catheter tip on CXR
◒ Pulmonary infarction
54b

1. tricuspid or pulmonary valve
mechanical prosthesis
2. right heart mass (thrombus / tumour)
3. tricuspid or pulmonary valve
endocarditis
55b

Management:of Pulmonary artery
rupture dt PAC
56a

◒ Deflate balloon, withdraw it 2 - 3 cm &
reinflate to tamponade
◒ Insert double lumen ETT, or advance existing
one to the opposite side, to isolate affected lung.
◒ Angiogram or bronchoscopy may isolate
affected vessel. Otherwise immediate lobectomy
if bleeding does not settle
◒ ↑PEEP may help
56b

pulmonary artery occlusion pressure
57a

◒ closely approximates LAP which
approximates LVEDP (wedge creates a
static column of blood)
57b

tip of the PA catheter must be in a lung region
where capillary (venous) pressure > alveolar
pressure (if not, the pressure at the tip of the PA
catheter will reflect the alveolar pressure) ➜
below the level of the LA ➜ ∴ tip of the PA
catheter should be below the level of the ➜ [ in
West's lung Zone 3: Pa > Pv > PA] ➜ Confirm by
lateral chest x-ray
58b

conditions where PAoP may mispresent
LVEDP:
60a

1. alveolar pressure > pulmonary venous pressure (i.e.catheter outside West's
zone 3)
2. pulmonary venous obstruction (atrial myxoma, pulmonary fibrosis,
vasculitis)
3. valvular heart disease:
MS (PAoP >LVEDP)
MR (PAoP >LVEDP)
AR (PAoP <LVEDP)
4. markedly reduced pulmonary vascular bed
- pneumonectomy
- massive PE
5. LV dysfunction (PAoP < LVEDP)
60b

◒ a bolus injected into the right atrium of cold
injectate transiently decreases blood temperature
in the pulmonary artery (monitored by a
thermistor proximal to the balloon)
◒ the mean decrease in temperature is inversely
related to COP
◒ margin of error with the technique is +/- 15%
61b

Causes of inaccurate cold thermodilution
cardiac output measures
62a

1. catheter malposition (wedge or vessel wall)
2. abnormal respiratory pattern (respiration causes
fluctuations)
3. intracardiac shunt
4. tricuspid regurge
5. arrhythmias
6. injectate port close to or within introducer sheath
7. abnormal haematocrit affecting blood density
8. extremes of cardiac output
9. poor technique (slow injection, incorrect injectate volume)
62b

◒ In summary, not helpful for predicting
fluid responsiveness (wedge pressure is
not related to LV function).
◒ OK for measuring CO & temperature
63b

The Cardiac Filling Pressures
64a

Central Venous Pressure = ?
66a

◒ In the absence of a tricuspid valve
abnormality ➜
CVP = RAP = RVEDP
66b

Pulmonary Capillary Wedge Pressure = ?
67a

◒ cardiac output adjusted for the size of
the patient.
◒ Cl = CO /BSA
◒ The average-sized adult has a BSA of
1.6 to 1.9 m2, so the cardiac index is
normally about 50 to 60% of the
measured cardiac output.
68b

◒ Stroke Volume: 1 ml/kg
◒ Stroke Volume is reflection of the
systolic performance of the heart,
◒ stroke volume should be adjusted for
body size
SI = CI /HR
69b

Systemic Vascular Resistance Index
70a

SVRI = (MAP - CVP) /CI
pressure drop across the systemic
circulation, or the
(MAP - CVP)/COP but adjusted for body
surface area will be /CI
70b

Pulmonary Vascular Resistance Index
71a

◒ PVRI = (PAP - PCWP) /Cl
◒ pressure gradient across the lungs, or
the mean PAP minus the left-atrial or
wedge pressure (PAP - PCWP)/COP but
adjusted for body surface area will be /CI
71b

◒ The rate of oxygen transport in arterial
blood
◒ D02 = CO x (1,34 x Hb x Sa02) x 10
◒ 1.3 x Hb x Sa02 = the arterial O2
content (CaO2),
72b

◒ the rate at which oxygen is taken up
from the systemic capillaries into the
tissues
◒ V02 = CO x 1.34 x Hb x (Sa02 - Sv02) x
10
73b

◒ the fractional uptake of oxygen from
the systemic microcirculation, and is
equivalent to the ratio of 02 uptake to 02
delivery
◒ O2ER=VO2/D02
74b

Value of SVV [Stroke Volume Variation]
75a

Volume is one of the first therapeutic
interventions selected when optimizing
DO2
SVV answers the question "Can using
fluid improve
hemodynamics?" and, "Is it the
appropriate intervention?"
75b

◒ a naturally occurring phenomenon in which
the arterial pulse pressure ↓during inspiration
and ↑during expiration dt changes in intra-
thoracic pressure dt NPV (spontaneous
breathing).
◒ Variations > 10mmHg referred to as pulsus
paradoxus. normal range of variation in
spontaneously breathing pts bw 5-10mmHg
76b

How Can I Use SVV? [Passive Leg
Raising ]
77a

◒ Raise legs to 45 degree (you have just
given a "blood bolus" 500 ml blood in
legs returned to the heart)
• Wait 30-60-90 sec (highest values
within 90 sec)
• Recheck the stroke volume
- SVV> 12% ➜ ∴ fluid responder
77b

patients must be:
-Passively ventilated- heavily sedated
-Large tidal volume 10-12 ml/kg
-Off vasopressors
-Sinus rhythm
-Absence of increased abdominal pressure 80b

CVP AS A MARKER OF
INTRAVASCULAR
VOLUME STATUS AND RESPONSE TO
FLUIDS
82a

• CVP is NOT RELIABLE for judging
intravascular volume status
• A low CVP generally can be relied upon
as supporting positive
response to fluid loading
• Target CVP 8-12 mmHg
82b

Higher target CVP of 12-15 mmHg
should be achieved
83a

- Mechanically ventilated patients
- ↓ventricular compliance
- Pulmonary artery hypertension
- Increased abdominal pressure
83b

Passive Leg Raising & Artery Peak
velocity
84a

• Doppler evaluation of arterial peak
velocity
variation
• in the responder pt, passive leg raising
induced an ↑arterial peak velocity by
15%
84b

• Measure proximaiiVC AP diameter 3 em from the
RA
• Spontaneous breathing
• >50% decrease in the IVC diameter with inspiration
predicts responsiveness to volume expansion
• Positive pressure ventilation
• > 12% increase in the IVC diameter with inspiration
predicts responsiveness to vo lume expansion
85b

Normal: IVC diameter 1-3 cm
86a

Volume Responsive: IVC diameter <1 cm
87a

Not Responsive: IVC diameter >3 cm
88a

Tips on Central Venous Catheter & Pulmonary Artery Catheter.

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