Download TUBES, CATHETERS and DEVICES

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: malpositioned
• Too high:
Can damage larynx.
Patient can extubate if
neck extended
Endotracheal tube: malpositioned
• 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: malpositioned
• 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 brachiocepahlic 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
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