1. Central Venous Lines and Thoracic Drainage Division of Cardiothoracic Surgery UWI Mona

2. Central Venous Lines: Why? To monitor / ascertain hydration status To administer fluids / nutrition To administer medications To gain access to the right side of the heart and pulmonary arterial tree

3. Anatomy of Central Venous Access

4. CV Lines: Multiple Access Sites

5. Access Sites, continued Central venous lines can also be placed by gaining access from peripheral veins (basilic, cephalic, femoral)  Peripherally-inserted central catheter  “PICC” lines

6. Implantation Techniques Sterile Technique Seldinger Method Placement of needle inside vein. Guide wire through needle into vein, needle removed. Dilator over guide wire, dilator removed, wire left in vein. Catheter over guide wire into vein, guide wire removed, catheter left in situ. Safest, surest method of cannulation of vessels yet devised.

7. Seldinger Technique

8. Other Techniques: Open (Venesection) Catheter-thru-Needle

9. Other Techniques, con’td Catheter-over-Needle Catheter-thru-cannula

10. Complications of CV lines Incorrect puncture –Into tissues –With perforation of vessel (out the other side) –With arterial damage –Into pleural cavity  pneumo, haemothorax –With nerve damage (brachial plexus)

11. Complications, con’td Incorrect Catheter Position –In another vein (non-central, ascending) –Lumen openings outside venous lumen –Catheter positioned too far into right atrium  incorrect pressure interpretation  cardiac dysrhythmias  cardiac perforation

12. Complications, con’td Embolism –Catheter Embolism –Guidewire Embolism –Air Embolism Treatment may need to be immediate or adopt “wait and see” policy

13. Other Complications Thrombosis Local Infection Local Haemorrhage Disseminated Infection –(catheter-related septicaemia)

14. Hydration Status and Monitoring In general: Central Venous Pressure 5 to 15 mmHg < 5 mmHg  HYPOVOLEMIA > 15 mmHg  HYPERVOLEMIA THIS IS ONLY TRUE FOR NORMAL, IDEALIZED INDIVIDUAL

15. Fluid Status / Monitoring Ill patients are much more variable An ill patient may be hypervolemic with a CVP of 10, or may be hypovolemic with a CVP of 16 Use of the CV pressure monitoring line allows for close and precise evaluation of the patients’ intravascular volume status

16. A Typical CV catheter: One or more (up to 3) lumina for simultaneous pressure monitoring and fluid / drug administration

17. Swan-Ganz Catheter Inserted into central vein via Seldinger technique, then advanced into pulmonary artery branch using pressure curves to guide placement

18. Swan-Ganz Catheter When advanced into PA, blowing up of balloon gives information as to the LEFT ATRIAL PRESSURE, which relates directly to the filling pressure of the left ventricle, and from which detailed calculations of CARDIAC OUTPUT can be derived (thermodilution technique)

20. Swan-Ganz: Pressures during insertion

21. CVP, Swan-Ganz, Chest Tubes in situ:

22. CV lines: Nutrition, Meds, Access to R. Heart Nutrition: TPN (total parenteral nutrition) Medications: Chemotherapy, vaso- sclerosant meds Access: eg. Pacemaker wires Cardiac Biopsy

23. Pacemaker in situ (via CV access)

24. Chest Intubation (Tube Thoracostomy) : Why? A procedure which becomes necessary when the pleural space contains air or fluid (blood, chyle, pus, bile, gastric contents, bowel contents, other fluids) in order that those abnormal contents can be drained and the underlying lung be allowed to re-expand to fill the pleural cavity

25. Pleural space is “potential space”

27. Tube Thoracostomy: When? Following trauma (accidental, operative) Following spontaneous pneumothorax Following the development of a pus- filled chest after pneumonia or penetrating trauma (empyaema thoracis)

28. Chest Tube: How does it work? Fluid/Air drains into 1 st bottle. Tube under H20 acts as a one-way valve  fluid/air out, but not back in. Second bottle is a fluid trap. Third bottle allows for safe application of suction

29. Fluid in Pleural Space: Pus = Empyaema Thoracis Blood = Haemothorax Blood + Air = Haemopneumothorax

30. Chest Intubation: How?

31. Chest Intubation: The tube

32. Sites for Chest Intubation NB. Unusual sites are dictated by location of fluid collections

33. Incise Make a linear incision along the rib, one interspace below the site of insertion of the tube

34. Dissect Insert a curved clamp and tunnel superiorly to the interspace that is to be entered Avoid the neurovascular bundle at the inferior margin of the rib

35. Puncture Gently but forcibly puncture through the intercostal muscles and parietal pleura. A gush of air and/or blood will exit through the wound. Avoid injuring the lung tissue when puncturing the pleura

36. Insertion Insert a finger into the pleural space to identify and separate pleural adhesions With the clamp, grasp the tip of the chest tube and advance it into the thorax

37. Secure the tube Direct the catheter posteriorly, superiorly Secure the tube –Use an 0 silk suture into the skin through the incision. Come out through the opposite side. Then, wrap the suture around the tube several times and tie it securely in place.

38. Chest Intubation: Results can be dramatic and life saving!

39. Chest Tubes: Caveats Excessively rapid drainage of fluid/air can result in too rapid re-expansion of ipsilateral lung leading to: RE-EXPANSION PULMONARY OEDEMA (not well understood) NEVER clamp a chest tube, unless directed to do so by a chest surgeon!!

40. Conclusions Central venous line insertion and chest intubation are two essential clinical skills Both procedures are highly technical and may have complications, but modern techniques have greatly reduced adverse events