Lines and Tubes - Interventional Radiology PDF

Lines and Tubes  Objectives of the lecture By the end of lecture students should be: ▀Recall the basic information concerning tube / line insertion ▀ Develop the ability of performance tube / line insertion ▀ Illustrate the purpose, indication, and necessary patient preparation for each...

Lines and Tubes  Objectives of the lecture By the end of lecture students should be: ▀Recall the basic information concerning tube / line insertion ▀ Develop the ability of performance tube / line insertion ▀ Illustrate the purpose, indication, and necessary patient preparation for each type of tube / line insertion  Medical tube Medical tubing is designed for a number of applications that allow clinicians to administer fluid and devices or allow for gas flow. Common applications of medical tubing include ventilators and IVs, but tubing also finds uses supporting access devices and as a delivery method for other devices.  Medical tubing is also one of the most popular types of tubing technology that are helpful in complex surgeries. Further, they have been designed for countless applications as well as they allow clinicians to control devices or fluid. Moreover, this tubing also allows for gas flow. You can easily see their uses in IVs and ventilators. In addition, they are also useful to support the access devices and also as a delivery method for several devices  What are the common lines? Central venous catheters Nasogastric tubes Endotracheal tubes Intercostal chest drains Cardiac Pacemaker  Line insertion Line insertion can be thought of as lines placed over a wire in the conventional fashion and lines intended for long-term access, which are placed in conjunction with a subcutaneous tunnel. To place a conventional line, follow the principles of ultrasound-guided vascular access.  Equipment A suitable line. Most proprietary devices come complete with the basic equipment necessary for placement. It is helpful to have some catheters and wires in reserve for difficult cases Forceps for blunt dissection Guidewires: angled hydrophilic, Amplatz super-stiff Catheters: Cobra II Ultrasound machine: this is essential; a linear 5-MHz or 7- MHz probe with a biopsy guide is ideal Heparin solution to ‘lock’ the catheter  Procedure There are three stages to the insertion of all tunnelled lines: Venous access – this is always the first stage Tunnelling Line positioning Venous access: The right internal jugular vein IJV is the first choice route for central venous catheterization. The jugular vein seems less prone to thrombosis than other routes. Access may be dictated by the presence of local disease, radiotherapy or stenosis/occlusion of the target vein. Tunnelling: This dictates whether you tunnel towards or away from the skin incision! The line exit site is usually on the anterior chest wall; you can check the line length again before committing. Line insertion: The line is always introduced through a peel-away sheath. Line positioning: The tip should be advanced just into the right atrium. The line invariably ends in the SVC when the patient is erect and takes a full inspiration for the chest X-ray. The sheath is then peeled away keeping your index finger on the catheter to hold it in position. Give a gentle pull on the catheter at the skin exit and the curve should pop under the skin leaving the cuff 2 cm in the tunnel.  Dialysis lines Successful dialysis depends on removing blood from one site (arterial line) and returning it to a separate site (venous line), typically more centrally in the venous circulation. If the lines are too close together or the venous line is proximal to the arterial line, dialysis will not be effective as the blood will simply recirculate. The separation is ensured in two ways: Use of two separate lines, e.g. Tesio lines. This requires two separate venous punctures and tunnels. The venous line is longer than the arterial line. Two lines are fine when there is good venous access but increases the problem when there is limited access. Use of a dual-lumen line, e.g. Ash Split catheter. These involve a single puncture and tunnel. The line is typically large, e.g. 14.5F.  Why the CXR is useful in Tubes and Lines To check it is in the right position To check for complications of placement of the tube/line  Central Venous Catheters Uses: – Rapid fluid replacement – Monitoring of central venous pressure – Administration of some drugs May be inserted from either subclavian or internal jugular vein The tip should lie within the superior vena cava Optimum Position Lateral to thoracic spine, inferior to medial end of right clavicle  Right internal jugular venous line in good position (red arrow) The tip of this left internal jugular venous line lies at the origin of the SVC (green arrow)  What can go wrong with central venous catheters? Complications are rare (5cm above the bifurcation of the trachea (carina)  Good position of Endotracheal Tube Tip of tube (red arrow) lies in good position, above the carina (green arrow) What can go wrong with ET Tubes? Tube too far advanced – Typically, within right main stem bronchus Placement within oesophagus Tracheal perforation Misplaced ET Tube Tip of ET tube in right main stem bronchus. The patient is at risk of left lung collapse Note abnormal enlarged left hilum (lung cancer)  Cardiac Pacemakers Used to treat conduction abnormalities Pacemakers may be single chamber (pacing lead embedded in right ventricular wall) or dual chamber (second lead embedded in right atrial wall) They are usually inserted via subclavian veins  Dual Chamber Cardiac Pacemaker Pacing leads in Leads in superior left subclavian vena cava vein Pacemaker Right atrial lead Right ventricular lead Note that there are no sharp bends in the leads  Problems with Pacemakers At insertion: – Pneumothorax – Vascular trauma – Cardiac wall puncture Delayed – Lead migration – Lead fracture Pacing Problem This patient had a single chamber pacemaker inserted several years ago, but the pacemaker no longer works. Can you tell why? Misplaced pacing lead The ventricular lead has become detached and now lies coiled within the right atrium. It should lie in the region of the red circle  Take Home Points A CXR can be used to identify the position of drains, tubes and lines A CXR is also used to check for complications of these devices, which may occur at the time of insertion or later  Guidelines for tube / line Care You must always wash your hands carefully for 15 seconds before and after working with the tube / line. Anyone who helps you with tube / line 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 tube / line and anything that goes into the tube / line must be sterile. Your nurse will show you how to care for the tube / line properly. The following guidelines are helpful in preventing infection:  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.