Lines and Drains VuAnh Truong February 2013 Paul Lewis, M.D.
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Transcript of Lines and Drains VuAnh Truong February 2013 Paul Lewis, M.D.
Lines and Drains
VuAnh Truong
February 2013
Paul Lewis, M.D.
• 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
Purpose
2
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 atrium1 lead tip in Right ventricle,1 lead tip in Coronary sinus *
NG tubeTube must be in stomach which is below the diaphragm. At least 10 cm of tube should extend into stomach. **
Endotracheal Tube4-7 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 idealFor 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.
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
Central Lines
4
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.
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
Central Lines
5
Au-Yong, Iain, Amy Au-Yong, and Nigel Broderick. On-call X-rays Made Easy. Edinburgh: Churchill Livingstone/Elsevier, 2010. Print.
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
Central Lines
6
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.
Uses:
Swan-Ganz catheters
* Aid in differentiating cardiac from non-cardiac pulmonary edema
Pulmonary Artery Catheters
7
Inhaltliche Referenz: Jochen Schulte am Esch: Anästhesie. Intensivmedizin, Notfallmedizin, Schmerztherapie. Stuttgart: Thieme, 3. Aufl., 2007.
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
Pulmonary Artery Catheters
8
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
Complications:
Pulmonary infarction from occlusion by catheter or from embolization off of catheter
Cardiac arrhythmia
Pulmonary artery perforation
Intracardiac knotting
Pulmonary Artery Catheters
9
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 infarctionhttp://openi.nlm.nih.gov/detailedresult.php?img=3190489_IJRI-21-182-g013&req=4
Uses:
Tx of cardiac arrhythmias
* there are different devices:
- Single lead, dual lead, biventricular, ICD
Pacing Devices
10
http://www.memorialcare.org/medical_services/heart-care/pacemaker.cfm
Correct Placement:
Single-lead pacemaker– 1 lead tip at Right Ventricle
Pacing Devices
11
http://radiopaedia.org/images/829693http://www.chw.org/display/PPF/DocID/23083/router.asp
Correct Placement:
Dual- lead pacemaker:
- 1 lead tip at the right atrium
- 1 lead tip at the right ventricle
Pacing Devices
12
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/
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
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
Pacing Devices
13
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
Correct Placement:
ICD – have segments of opaque coils along each lead
- One electrode in SVC or brachiocephalic vein
- One lead in right ventricle
Pacing Devices
14
http://my.clevelandclinic.org/heart/services/tests/procedures/icd.aspx
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
Pacing Devices
15
www. Cartoonstock.com
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
Pacing Devices
16
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.
Uses:
NG feeds.
Medication delivery.
GI decompression.
Dx of UGIB
Nasogastric Tube
17
http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Eatingwell/Nutritionalsupport/Nutritionalsupport.aspx
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.
Nasogastric Tube
18
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.
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
Nasogastric Tube
19
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.
Uses:
Airway protection
Mechanical ventilation
Endotracheal Tube
20
{{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
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)
Endotracheal Tube
21
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.
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
Endotracheal Tube
22
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.
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
Tracheostomy Tube
23
http://www.nhlbi.nih.gov/health//dci/Diseases/trach/trach_during.html
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
Tracheostomy Tube
24
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
Complications:
Subcutaneous emphysema
Pneumomediastinum
Pneumothorax
Tracheal stenosis
Tracheostomy Tube
25
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.
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
Pleural Drainage Tubes
26
American Accreditation HealthCare Commission (www.urac.org)
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.
Pleural Drainage Tubes
27
Thoracostomy tube In basal position.
BELLIGUND P, JAMALEDDINE G. NAUSEA, VOMITING AND ABDOMINAL PAIN WITH PLEURAL EFFUSION. AMERICAN THORACIC SOCIETY.
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.
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
Pleural Drainage Tubes
28
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.