TUBES, CATHETERS and DEVICES …and when they go BAD

A dr Z Lecture On the placement (and misplacement) of monitoring and therapeutic devices in the critically ill patient

Radiography It is mandatory to check for position and complications after placing ANY device within a patient! Radiography is definitive! Clinical evaluation is NOT sufficient!

Devices MOVE! In critically ill patients, you must RECONFIRM the position of ALL devices at least every day.

Complications HAPPEN! Another reason to recheck critically ill patients is to detect complications and correct them. The complications can be device-related or not, but they are frequent and can be serious or life threatening.

ICU PATIENTS It IS necessary to re-check the position of ALL devices and to look for complications EVERY 24 hours in all ICU patients, by getting a Portable Chest Radiograph.

How Frequent? In recent studies, 25% of ICU portable chest radiographs showed an adverse change in position of a device, or a complication that needed intervention!

The Devices Nasogastric (NGT) and oral gastric tubes Endotracheal tubes (ETT) Vascular catheters Pacemakers, AICDs, Swan-Ganz catheters, chest tubes, etc.

The Complications Pneumothorax Pneumomediastinum Obstructive atelectasis Pleural and mediastinal fluid Pulmonary infarction Pulmonary edema Aspiration and pneumonia

ENDOTRACHEAL TUBES ETT

Endotracheal Tubes: optimally positioned Tip about 5 cm above the carina Tip at top 1/3rd of aortic arch

Endotracheal Tube: optimal position

Endotracheal Tubes: mal- positioned Too high: Can damage larynx. Patient can extubate if neck extended

Endotracheal tube: mal- positioned Too low: If patient’s head is flexed, ETT can enter right mainstem bronchus

ETT: malpositioned Too low: The ETT can easily enter the right main stem bronchus. It likes to go there-don’t let it!

ETT: too low ETT has entered right main stem bronchus ETT has obstructed the left mainstem bronchus and collapse the left lung If mechanically ventilated, can cause a right pneumothorax also

Endotracheal Tube: mal- positioned Esophageal intubation An ETT in the esophagus does not ventilate the patient Hypoxia results, with serious or fatal consequences

Esophageal Intubation: signs ETT tip below carina Part of ETT outside trachea wall Balloon overlaps trachea walls Trachea visible outside of ETT

Esophageal Intubation

Nasogastric Tubes NGT

Nasogastric tubes Tip of NGT must be at least 10 cm distal to the gastroesophageal junction There is a side hole at 7 cm. If above the ge junction, can lead to aspiration

NGT: good position

NGT: the ge junction

NGT: the side hole

NGT: too high

NGT: coiled in pharynx

NGT: in right bronchus

Vascular Catheters and Devices

Catheters and Devices Venous access catheters Central venous catheters Swan-Ganz catheters Pacemakers

Vascular Catheters Placement and Landmarks

Venous Catheter placement Ideally, in the superior vena cava Acceptable, in the brachio-cephlic veins Marginal, in the right atrium

Venous Landmarks Subclavian vein: thoracic margin to head of clavicle, where it joins Internal Jugular vein, to become the Brachio-cephalic vein

Venous Landmarks, upper To find the junction of the two brachio- cepahlic veins and so origin of Superior Vena Cava, Follow the curve of the lower margin of the right First Rib to the right paramidline

Venous Landmarks, upper

Venous Landmarks, lower To find the termination of the Superior vena Cava at the Right Atrium, look for the convex lateral curve of the heart

Venous Landmarks, lower

Review: Venous Landmarks

Venous Catheter placement: ideal

Venous catheter placement: marginal

Misplaced catheters Venous Aterial Extra-vascular

Misplaced catheter: venous In addition to too far or not far enough, places to avoid are: Internal jugular vein Azygos vein Internal mammary vein

Misplaced catheter: Internal Jugular vein

Misplaced catheter: Azygos vein

Venous catheter: subclavian artery to aorta

Extra-vascular catheter placement IV fluid infuses into mediastinum, pleural space, or extrapleural space Pneumothorax, pneumomediastinum may occur When in doubt, do CT Chest.

Swan-Ganz Catheter Ideal placement is tip in right or left pulmonary artery More peripheral placement can cause an infarct if wedged into a small artery

Swan-Ganz Catheter: good placement

Swan-Ganz Catheter: too far

Pacemakers Leads are in the right atrium and right ventricle; some units have a third lead in the coronary sinus. Some are also AICD

Pacemaker

So….. Don’t ASSUME a device is OK CONFIRM the placement of ALL devices by radiology imaging RECONFIRM the position of ALL devices EVERY DAY in critically ill patients

Goodbye… Copyright 2005 Michael Zucker, MD