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

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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

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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

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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

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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)


Uses:

Swan-Ganz catheters

* Aid in differentiating cardiac from non-cardiac pulmonary edema

Pulmonary Artery Catheters

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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


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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


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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

http://openi.nlm.nih.gov/detailedresult.php?img=3190489_IJRI-21-182-g013&req=4

http://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

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http://www.memorialcare.org/medical_services/heart-care/pacemaker.cfm

Correct Placement:

Single-lead pacemaker– 1 lead tip at Right Ventricle

Pacing Devices

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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

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Correctly positioned dual-chamber permanent pacemaker device. The pacemaker box is positioned subcutaneously, usually in the left upper thorax (arrow 1).


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

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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

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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

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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

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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

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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

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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

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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


Uses:

Airway protection

Mechanical ventilation

Endotracheal Tube

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{{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

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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).


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

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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)


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

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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

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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:


Pneumomediastinum

Pneumothorax

Tracheal stenosis

Tracheostomy Tube

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Frontal chest radiograph shows complications of tracheostomy: pneumothorax (straight arrow), pneumomediastinum (curved arrow), and surgical emphysema (notched arrow)


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

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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.


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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


Empyema


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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.


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

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