TUBES, CATHETERS and DEVICES …and when they go BAD.
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Transcript of TUBES, CATHETERS and DEVICES …and when they go BAD.
![Page 1: TUBES, CATHETERS and DEVICES …and when they go BAD.](https://reader036.fdocuments.net/reader036/viewer/2022062320/56649d1f5503460f949f271f/html5/thumbnails/1.jpg)
TUBES, CATHETERS and DEVICES
…and when they go BAD
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A dr Z Lecture
• On the placement (and misplacement) of monitoring and therapeutic devices in the critically ill patient
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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!
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Devices MOVE!
• In critically ill patients, you must RECONFIRM the position of ALL devices at least every day.
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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.
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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.
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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!
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The Devices
• Nasogastric (NGT) and oral gastric tubes
• Endotracheal tubes (ETT)
• Vascular catheters
• Pacemakers, AICDs, Swan-Ganz catheters, chest tubes, etc.
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The Complications
• Pneumothorax
• Pneumomediastinum
• Obstructive atelectasis
• Pleural and mediastinal fluid
• Pulmonary infarction
• Pulmonary edema
• Aspiration and pneumonia
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ENDOTRACHEAL TUBES
ETT
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Endotracheal Tubes: optimally positioned
• Tip about 5 cm above the carina
• Tip at top 1/3rd of aortic arch
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Endotracheal Tube: optimal position
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Endotracheal Tubes: mal- positioned
• Too high:
Can damage larynx. Patient can extubate if neck extended
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Endotracheal tube: mal- positioned
• Too low:
If patient’s head is flexed, ETT can enter right mainstem bronchus
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ETT: malpositioned
• Too low:
The ETT can easily enter the right main stem bronchus. It likes to go there-don’t let it!
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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
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Endotracheal Tube: mal-positioned
• Esophageal intubation• An ETT in the
esophagus does not ventilate the patient
• Hypoxia results, with serious or fatal consequences
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Esophageal Intubation: signs
• ETT tip below carina• Part of ETT outside
trachea wall• Balloon overlaps
trachea walls• Trachea visible
outside of ETT
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Esophageal Intubation
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Nasogastric Tubes
NGT
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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
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NGT: good position
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NGT: the ge junction
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NGT: the side hole
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NGT: too high
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NGT: coiled in pharynx
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NGT: in right bronchus
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Vascular Catheters and Devices
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Catheters and Devices
• Venous access catheters
• Central venous catheters
• Swan-Ganz catheters
• Pacemakers
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Vascular Catheters
Placement and Landmarks
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Venous Catheter placement
• Ideally, in the superior vena cava
• Acceptable, in the brachio-cephlic veins
• Marginal, in the right atrium
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Venous Landmarks
• Subclavian vein: thoracic margin to head of clavicle, where it joins Internal Jugular vein, to become
the Brachio-cephalic vein
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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
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Venous Landmarks, upper
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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
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Venous Landmarks, lower
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Review: Venous Landmarks
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Venous Catheter placement: ideal
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Venous catheter placement: marginal
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Misplaced catheters
• Venous• Aterial• Extra-vascular
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Misplaced catheter: venous
• In addition to too far or not far enough, places to avoid are:
Internal jugular vein
Azygos vein
Internal mammary vein
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Misplaced catheter: Internal Jugular vein
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Misplaced catheter: Azygos vein
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Venous catheter: subclavian artery to aorta
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Extra-vascular catheter placement
IV fluid infuses into mediastinum, pleural space, or extrapleural space
Pneumothorax, pneumomediastinum may occur
When in doubt, do CT Chest.
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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
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Swan-Ganz Catheter: good placement
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Swan-Ganz Catheter: too far
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Swan-Ganz Catheter: too far
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Pacemakers
• Leads are in the right atrium and right ventricle; some units have a third lead in the coronary sinus. Some are also AICD
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Pacemaker
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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
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Goodbye…
Copyright 2005
Michael Zucker, MD