Lines and Drains February 2013 VuAnh Truong Paul Lewis, M.D.

Learn Uses, correct placement, and complications of the following: Purpose Learn Uses, correct placement, and complications of the following: Central Venous Catheters Pulmonary Artery Catheters Pacemakers/ICDs NG tube Endotracheal Tube Tracheostomy Tube Pleural Drainage Catheters

Tube/catheter Correct Position Citation Central Venous Catheters Tip of catheter should be in SVC (between the origin of the SVC and the SVC-Right Atrial junction) * Pulmonary Artery Catheter Tip should be within right or left pulmonary artery, 2 cm from the Hila Single-lead pacemaker/ICD 1 lead tip at Right Ventricle Dual- lead pacemaker: 1 lead tip at the right atrium, 1 lead tip at the right ventricle Biventricular pacemakers 1 lead tip in Right atrium 1 lead tip in Right ventricle, 1 lead tip in Coronary sinus NG tube Tube must be in stomach which is below the diaphragm. At least 10 cm of tube should extend into stomach. ** Endotracheal Tube 4-7 cm above carina when pt head and neck in neutral position. Tracheostomy Tube Tip half-way between stoma and carina (3-5 cm above carina) Pleural Drainage Tubes For Pneumothorax – cephalad position is ideal For pleural effusion – basal position is ideal * Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print. ** Jain SN. A pictorial essay: Radiology of lines and tubes in the intensive care unit. Indian J Radiol Imaging. 2011;21(3):182-90.

Central Lines Uses: Administration of meds, feeds, fluids Monitoring CVP * There are several types of central lines (i.e. Permcarths, Hickman, portacaths,) * interpreting placement for each of them are the same. * SVC is the preferred location for measuring CVP Diagrammatic representation of the last valves in the internal jugular vein (curved arrow) and subclavian veins (notched arrow). The valves are located near the inner aspects of the first ribs. The brachiocephalic veins join to form the superior vena cava (straight arrow) near the 1st anterior intercostal space. The cavoatrial junction (arrowhead) is where the superior vena cava crosses the bronchus intermedius Jain SN. A pictorial essay: Radiology of lines and tubes in the intensive care unit. Indian J Radiol Imaging. 2011;21(3):182-90.

Central Lines Correct Placement: Tip of catheter should be in SVC (between the origin of the SVC and the SVC-Right Atrial junction) * always check for complications with central lines (below) * routes of access may vary (i.e. internal jugular, external jugular, subclavian Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.

Central Lines Complications: Pnuemothorax Mediastinal hematoma Ectopic infusion of fluid into mediastinum/pleural space Catheter breakage and embolization Puncture of subclavian artery Air embolization Venous perforation Thrombosis Malposition - Opposite subclavian vein - IJ vein w/ tip directed cephalad - Corresponding artery - R atrium - R ventricle - Extrathoracic location http://radiologyspirit.blogspot.com/2010/07/misplaced-ett-down-right-mainstem.html Widened mediastinum following CVP line insertion. The presence of a wide mediastinum raises concern about mediastinal haematoma (arrow 1). Left internal jugular central line (arrow 2) Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.

Pulmonary Artery Catheters Uses: Swan-Ganz catheters * Aid in differentiating cardiac from non-cardiac pulmonary edema Inhaltliche Referenz: Jochen Schulte am Esch: Anästhesie. Intensivmedizin, Notfallmedizin, Schmerztherapie. Stuttgart: Thieme, 3. Aufl., 2007.

Pulmonary Artery Catheters Correct Placement: Tip should be within the right or left pulmonary artery, 2 cm from the Hila * Balloon is inflated only when measurements are made http://radiologyspirit.blogspot.com/2010/07/misplaced-ett-down-right-mainstem.html Chest x-ray showing location of Swan-Ganz catheter tip (arrow) in the right pulmonary artery. http://www.radiologyschools.com/radiology-courses/chest/PCWP1.htm

Pulmonary Artery Catheters Complications: Pulmonary infarction from occlusion by catheter or from embolization off of catheter Cardiac arrhythmia Pulmonary artery perforation Intracardiac knotting Frontal chest radiograph shows the tip (curved arrow) of a Swan-Ganz catheter (straight arrows) lying in the descending branch of the right pulmonary artery. The right paracardiac opacity is due to pulmonary infarction http://openi.nlm.nih.gov/detailedresult.php?img=3190489_IJRI-21-182-g013&req=4

Pacing Devices Uses: Tx of cardiac arrhythmias * there are different devices: - Single lead, dual lead, biventricular, ICD http://www.memorialcare.org/medical_services/heart-care/pacemaker.cfm

Pacing Devices Correct Placement: Single-lead pacemaker– 1 lead tip at Right Ventricle http://www.chw.org/display/PPF/DocID/23083/router.asp http://radiopaedia.org/images/829693

Pacing Devices Correct Placement: Dual- lead pacemaker: - 1 lead tip at the right atrium - 1 lead tip at the right ventricle This chest radiograph shows a dual chamber pacemaker. There are two pacing leads – one in the right atrium and another in the apex of the right ventricle (labelled B). The right atrial lead is displaced (labelled A). Melarkode K, Latoo MY. Pictorial essay III: Permanent pacemakers and Oesophageal Doppler probe. BJMP 2009: 2(3) 66-68 Correctly positioned dual-chamber permanent pacemaker device. The pacemaker box is positioned subcutaneously, usually in the left upper thorax (arrow 1). Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print. http://www.odec.ca/projects/2007/torr7m2/

Pacing Devices Correct Placement: Biventricular pacemakers * have 3 leads 1 lead tip in Right atrium 1 lead tip in Right ventricle 1 lead tip in Coronary sinus Leads pass through the left subclavian vein. Three pacemaker leads – the 1st lead is situated in the right atrium (J shaped wire- labelled A), the 2nd lead is in the apex of the right ventricle (labelled B) and the 3rd lead in the lateral wall of the left ventricle (labelled C). Pacing the apex of the right ventricle and the lateral wall of the left ventricle simultaneously improves the co-ordination of the left ventricular contraction 2. Biventricular pacemakers are used as cardiac synchronisation therapy in patients with cardiac failure.  Melarkode K, Latoo MY. Pictorial essay III: Permanent pacemakers and Oesophageal Doppler probe. BJMP 2009: 2(3) 66-68

Pacing Devices Correct Placement: ICD – have segments of opaque coils along each lead One electrode in SVC or brachiocephalic vein One lead in right ventricle http://my.clevelandclinic.org/heart/services/tests/procedures/icd.aspx

Pacing Devices Causes of Failure to elicit a ventricular response: Lead fracture** Electrode malposition** Myocardial perforation** Electrode dislodgment Exit block Thrombosis Infection Battery failure ** these can be indentified on chest radiographs www. Cartoonstock.com

Pacing Devices Complications: Pneumothorax Lead malposition Subcutaneous emphysema Twiddler’s syndrome – rare, pt w/ pacemaker/ICD consciously or unconsciously twist and rotate the implanted device, resulting in torsion, dislodgment, and fracture of implanted lead Figure 2. Pacemaker lead without loop in the inferior vena cava and atrial dipole displaced to the superior vena cava, with evidence of “lead twiddling” in the pacemaker pocket. Gonçalves E, Garcia R, Vaz MT. [Twiddler syndrome in a pediatric patient]. Rev Port Cardiol. 2011;30(12):939-40.

Nasogastric Tube Uses: NG feeds. Medication delivery. GI decompression. Dx of UGIB http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Eatingwell/Nutritionalsupport/Nutritionalsupport.aspx

Nasogastric Tube Correct Placement: Tube must be in stomach which is below the diaphragm. At least 10 cm of tube should extend into stomach The trick for the NG tube is the tube has to bend/curve medial to the medial edge of the left hemi-diaphraghm.  * The most dangerous cases are the cases in which the tube is erroneously placed into the left main stem bronchus and project over the stomach but actually sit within the left posterior sulcus. This patient has an appropriately positioned NG tube. Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.

Nasogastric Tube Consequences of Improper Placement: If in trachea w/ tube feed  risk of pneumonia If in lung, recommend getting lateral decubitus CXR to evaluate for pneumothorax. - Right lateral decubitus if placed in the left lung - Left lateral decubitus if in the right lung. If in esophagus  risk of aspiration Pneumothorax Frontal radiograph of the chest shows a NG tube forming a loop in the left bronchus (arrow) before the tip (arrowhead) reaches the right lower lobe bronchus Jain SN. A pictorial essay: Radiology of lines and tubes in the intensive care unit. Indian J Radiol Imaging. 2011;21(3):182-90.

Endotracheal Tube Uses: Airway protection Mechanical ventilation http://eduscapes.com/sessions/ems/1b.htm {{Information |Description=Diagram of an inserted endotracheal tube (10) |Source=http://patft.uspto.gov/netacgi/nph-Parser?patentnumber=6378523 |Date=March 15, 2000 |Author=Christopher; Kent L. |Permission=United States Patent illustration |other_versions

Endotracheal Tube Correct Placement: 4-7 cm above carina when pt head and neck in neutral position. * Neck flexion  2 cm descent of ETT (2-4 cm from carina) * Neck extension  2 cm ascent of ETT (7-9 cm from carina) This patient has an appropriately positioned ET tube (arrow 1). The ET tube tip should be approximately 5 cm, or a few vertebral body heights above the carina (arrow 2). Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.

Endotracheal Tube Complications of Improper Placement: Right mainstem ETT intubation  hypoventilation or collapse of left lung. Dislodgment of trachea. Placement in esophagus. Placement just beyond vocal cords and vocal cord injury with balloon inflation. Tracheal or laryngeal laceration. Tracheostenosis. Tracheomalacia. Aspiration Frontal chest radiographs show an endotracheal tube in the right main bronchus (arrowhead in A), causing hyperinflation of the ipsilateral lung and partial collapse of the left lung (curved arrow in A) Jain SN. A pictorial essay: Radiology of lines and tubes in the intensive care unit. Indian J Radiol Imaging. 2011;21(3):182-90.

Tracheostomy Tube Uses: Airway obstruction at or above larynx Respiratory failure requiring long-term intubation (> 21 d) Paralysis of muscles affecting swallowing or respiration Obstruction during sleep apnea http://www.nhlbi.nih.gov/health//dci/Diseases/trach/trach_during.html

Tracheostomy Tube Correct Placement: Tip half-way between stoma and carina (3-5 cm above carina) * Tip placement not affected by flexion/extension of neck * Width of tub usually ~ 2/3 width of trachea http://radiologyspirit.blogspot.com/2010/07/misplaced-ett-down-right-mainstem.html X ray taken post insertion of trachestomy tube with tip 5 cm above carina and no immediate signs of complications http://www.frca.co.uk/Documents/154%20Interpretation%20of%20the%20chest%20radiograph%20part%203.pdf

Tracheostomy Tube Complications: Subcutaneous emphysema Pneumomediastinum Pneumothorax Tracheal stenosis Frontal chest radiograph shows complications of tracheostomy: pneumothorax (straight arrow), pneumomediastinum (curved arrow), and surgical emphysema (notched arrow) Jain SN. A pictorial essay: Radiology of lines and tubes in the intensive care unit. Indian J Radiol Imaging. 2011;21(3):182-90.

Pleural Drainage Tubes Uses: Drainage of hemothorax, or large pleural effusion of any cause, empyema Drainage of large pneumothorax * There are large and small bore (pigtail drain) Treatment of pneumothorax  American Accreditation HealthCare Commission (www.urac.org)

Pleural Drainage Tubes Correct Placement: For Pneumothorax – Cephalad position is ideal For pleural effusion – Basal position is ideal * check to see if lung has reinflated, if not, consider bronchopleural fistula. Thoracostomy tube in Cephalad position Rosing JH, Lance S, Wong MS. Ulnar neuropathy after tube thoracostomy for pneumothorax. J Emerg Med. 2012;43(4):e223-5. http://radiologyspirit.blogspot.com/2010/07/misplaced-ett-down-right-mainstem.html Thoracostomy tube In basal position. Belligund P, Jamaleddine G. Nausea, vomiting and abdominal pain with pleural effusion. American Thoracic Society. Source: U.S. National Library of Medicine and the National Institutes of Health.

Pleural Drainage Tubes Complications: Unresolved/reaccumulation of pneumothorax Puncture of liver or spleen (hemoperitoneum; requires emergent laparotomy) Bleeding: local, hemothorax Passage of tube along chest wall instead to into chest cavity Subcutaneous emphysema Empyema Fig. 5.2 The difficulty in localization is illustrated here – this patient actually had a chest drain in the lung (arrow) as demonstrated later on a CT scan. If the drain is projected over the lung, it may be correctly placed in the pleural space or in the lung. Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.