SYDNEY NURSING SCHOOL

CVAD & Advanced Haemodynamic MonitoringEamon Merrick RN, BHSc UTS (NZ) MHSM UTS

Jane Currie NP, BSc City(UK) MScS'ton, RAANC

Outcomes

› This lecture will:

• introduce Central Venous Access Devices (CVAD), arterial lines (a or art-line), and invasive haemodynamic monitoring

• overview the indications, management, and potential complications of CVAD/ arterial lines

• discuss the principles of invasive haemodynamic monitoring

• review your role in the safe management of patients with CVAD/ arterial lines

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Definition

› Central Venous Access Device (CVAD)

• A catheter introduced via a large vein into the superior vena cava or right atrium for the administration of parental fluids, medications, or for the measurement of Central Venous Pressure (CVP)

- 15-20cm long single or multipurpose catheter

- Multiple lumens with multiple openings along the length of the catheter- proximal, medial, and distal.

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Basilic and Femoral Insertions

› Peripherally Inserted Central Venous Catheter (PICC)

› Tend to be used for long-term access

› Inserted into the cephalic, basilic, or brachial (cubital?)

- Minimal risk of pneumothorax or vessel perforation during insertion

- Durable and flexible

- Less risk of infection

- Vigorous exercise (swimming) should be avoided

- Infusion pump should be used due to lumen size

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Where are you likely to encounter CVAD

› There is a good chance that you will care for a patient with a CVAD if you work in a critical care setting i.e. emergency or intensive/ critical care- also likely in oncology settings

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Why?

› When might it be useful to have a CVAD?

- Remembering they are introduced via a large vein into the superior vena cava or right atrium.

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Indications

› Administration of fluid

› Monitoring of hydration status

› Monitoring of cardiac status

› Difficulties in finding alternative intravenous access

› Monitoring the effects of cardio-active agents i.e. inotropes, vasodilators

› Administration of potent medications

› Administration of Trans-Parental Nutrition (TPN)- why?

› Haemodialysis

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Insertion Points

› Internal Jugular

- Preferred site- improve chances of placement success and less risk of complications

- Easiest access with the shortest and straightest route

- Less risk of injury to the vagus nerve and carotid artery

Although… increase risk of occlusion and irritation due to head movement and problems with maintaining a intact dressing.

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Location of the Internal Jugular

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Internal jugular

External Jugular and Subclavian

› External jugular

Easy insertion

Varies from person- person in size

Angles into the subclavian (bendy insertion)

Subclavian

Preferred for long-term

Less vessel irritation and risk of occlusion due to rapid flow

Secures to chest wall

Potential for superior vena cava obstruction

Complications include pneumothorax an thrombosis

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External Jugular, Subclavian, Brachiocephalic (innominate), Superior vena cava

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External Jugular

Subclavian

Brachiocephalic

Superior vena cava

Basilic and Femoral Insertions

› Basilic

Usual site for the insertion of PICCs due to the shortest and straightest of the vein

Femoral

Good approach for children- tip rests in inferior vena cava

Increase risk of thrombosis and infection

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Basilic

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Basilic

Axillary

Subclavin

Brachiocephalic

Superior vena cava

Insertion and Management/ Risk Factors

› Anxiety

› Obesity

› Coagulopathy

› Anti-platelet medications

› Hypotension

› Proximal surgery

› Previous CVAD at site

› Infection at site

› Lymph node dissection or removal

› History of DVT in limb

› Pulmonary of pulmonary catheter- left bundle branch block14

Catheter Selection

› Planned approach based on the individual needs of the patient

- Minimise the number of lumens (why?)

- Should anti-microbial catheters be used?

- Multiple infusions and TPN, why is this a consideration?

- How long will the CVAD be insitu?

- Will this be a out-patient?

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Review- Central Venous Access Devices

› Central lines

- 15-20cm long single or multipurpose catheter

- Multiple lumens with multiple openings along the length of the catheter- proximal, medial, and distal.

- Used for:

- Alternative of peripheral access

- Administration of IV Fluids

- Administration of IV medications

- Administration of Trans-Parental Nutrition (TPN)

- Monitoring of Central Venous Pressure (CVP)

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Central Venous Access Devises- Complications

› During Insertion

- Pneumothorax- can occur with subclavian and jugular approaches where the plural cavity is punctured

- Haemorrhage- damaged vessel on insertion (patients with coagulopathies/ thrombocytopenia are at more risk)

- Air embolism

- Cardiac tamponade- Poor placement of the catheter tip can result in a puncture or swelling of the myocardium

- Dysrhythmias- due to a irritation of the right atrium

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Central Venous Access Devises- Complications

› Post-Insertion

- Air embolism

- Occlusion/ Thrombosis- inadequate flushing can result in a build up of fibrin or medication particulate- think incompatible medications

- Infection- contamination at time of insertion, insertion site or lumen, and/or the giving set.

- Pain- potentially indicative of poor placement and infection

- Dislodgement- normally accidental (not always)- what would do in this situation?

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Central Venous Access Devises- Removing

› Removal

- Aseptic technique

- Consider the individual needs of the patient

- Patient in a supine position with head tilted down- why?

- Patient to remain in a supine position for 30- 60 minutes

- Document removal and note presence (or otherwise) of intact tip

- Blood cultures and culture of tip if infective process suspected

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Preventing Occlusion

How can nursing professionals prevent the occlusion of a CVAD?

› Matthew, D., Mitchell, B. J. A., Williams, K., & Umscheid, C. A. (2009). Heparin flushing and other interventions to maintain patency of central venous catheters: a systematic review. Journal of Advanced Nursing, 65(10), 2007-2021.

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Preventing Infection

How can nursing professionals prevent infection/ sepsis in patients with a CVAD?

› New South Wales Health Department of Health. (2011). Central venous access device insertion and post insertion care. Sydney.

› Australian New Zealand Intensive Care Society. (2012). Central Line Insertion and Maintenance Guideline: ANZICS Safety and Quality Committee. Available from:

http://www.anzics.com.au/downloads/doc_download/649-anzics-central-line-insertion-a-maintenance-guideline-april-2012

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Air Embolism

Identify:

Sudden onset of cyanosis

Tachypnoea

Coughing

Tachycardia

Hypotension

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Air Embolism

Act:

Clamp the line

Turn the patients head to the opposing side of the line

Lie the patient flat on her/his left hand side

Get help!

Ask the patient to perform the ‘Valsalva’ manoeuvre (if conscious)

Goal:

Immediate medical management- possibly requiring aspiration, mechanical ventilation (100% O2), and pharmacologic circulatory support.

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SYDNEY NURSING SCHOOL

Advanced Haemodynamic MonitoringCentral Venous Pressure, Arterial Lines, and Wave Forms

Central Venous Pressure (CVP)

Continuous monitoring of of the pressure of blood in the right atrium or superior vena cava

Best interpreted as a trend- the cardiac function of the patient must be considered

Useful for estimating right ventricular pre-load- not systemic pressure/ perfusion

Remember that left-sided output determines systemic pressure and perfusion

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Central Venous Pressure (CVP)

› Raised CVP may indicate

- Right ventricular failure

- Cardiac tamponade

- Tricuspid valve incompetence

- Infusions in progress

- Catheter tip that is occluded or displaced

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Central Venous Pressure (CVP)

› Depressed CVP may indicate

- Ascites

- Vasodilation of peripheral veins

- Vasodilating medications

- Decrease circulatory blood volume (hypervolemia, dehydration)

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Central Venous Pressure Waveform

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Cardiac Cycle

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a c

x vy

Systole Diastole

LV

Arterial Lines

Allows:

The invasive real-time monitoring of blood pressure

useful when administering inotropic or cariotropic medications

The drawing of blood gases

The calculation of Mean Arterial Pressure (MAP)

The assessment of compromised aortic valves

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Watson, C. A., & Wilkinsin, M. B. (2011). Monitoring central venous pressure, arterial pressure and pulmonary wedge pressure. Anesthesia and Intensive Care Medicine, 13(3), 116-120.

Garretson, S. (2005). Haemodynamic monitoring: arterial catheters. Nursing Standard, 19(31), 55-64.

Modified Allens Test

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Checks the patency of the radial and ulnar arteries

Preformed prior to and post insertion of a arterial line

1. Elevate the hand and make a fist for 30 seconds

2. Apply pressure to both the ulnar and radial arteries

3. The hand is opened and should appear blanched

4. Release pressure on the ulnar artery and check for refill

Arterial Lines: Complications

Haemorrhage

Damage to artery

Embolism

Distress and anxiety

Pain

Obstruction (often caused by poor wrist placement)

Necrosis

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Arterial Line

Arterial Line Setup External Link

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Arterial Waveform

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Mean Arterial Pressure

Mean Arterial Pressure (MAP) is the pressure felt by the internal organs- it is not an average… as the duration of diastole exceeds that of systole

A MAP of at least 60mmHg is required to perfuse the coronary arteries, brain and kidneys.

A ‘normal’ range is about 70mmHg to to 110mmHg

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Cardiac Cycle

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a c

x vy