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Lines and Catheters

Seth Alexander

General guidance

  • Primary goals of line/catheter management:
    • Know why it was placed
    • Know where it is going (venous, arterial, potential space)
    • Know what needs to happn before it can be removed
  • Risk of infection: all foreign objects run the risk of introducing microbes during placement or becoming a nidus for microbial growth.
    • Lines should only be placed when medically necessary and removed as medically appropriate.
  • This chapter does not include additional forms of invasive monitoring devices (i.e., Swan Ganz catheters), surgical/procedural drains, or support devices (i.e., endotracheal tubes, ventricular assist devices, etc.) as these typically require subspecialty consultation/management for consideration and are discussed elsewhere.

Urinary Catheter

  • Indications: surgery, immobilization, urinary retention, need for strict urine output monitoring (critical illness, diuresis), and open sacral/perineal wounds with incontinence
  • Chronic foleys should typically be exchanged on admission
  • Duration of use is biggest risk factor for CAUTI
    • Best way to prevent CAUTI is to avoid inappropriate placement
    • Assess daily whether foley can be removed
  • Chronic Foleys generally should be exchanged at time of admission
  • Potential complications: Traumatic placement, difficult placement, and CAUTI
    • Any concern for catheter obstruction should prompt urgent urology consult
    • Determine if coudé catheter placement attempted; can be useful in patients with BPH
    • Duration of use is the biggest risk factor for CAUTI; assess daily for need
  • Criteria for removal: ability to void independently (with PVR follow-up) and resolution of placement indication
  • Alternate devices: Purewick catheter and condom catheter

Central venous catheter

  • Central venous access can be obtained through large central venous catheters (internal jugular, subclavian, or femoral CVC) or peripherally inserted central catheters (PICC).
  • Indications: Vasoactive infusions (pressors, inotropes), long-term antibiotics, inability to obtain peripheral access, caustic agent administration (chemotherapy, antibiotics, etc), and total parenteral nutrition
  • Note, single lumen PICC appropriate for most patients; double lumen typically reserved for special populations such as those in the ICU, on chemo, or on TPN
  • Potential complications:
    • Arterial cannulation, air embolization, thrombus, or mispositioning during placement
    • Highest risk of insertion: femoral CVC
    • Pneumothorax: Subclavian CVC
  • Criteria for removal: discontinuation of agents for which placement was indicated, transition to comfort care, or concern for central line associated bloodstream infection (CLABSI)
  • Alternative devices: peripheral venous access (consider US-guided)
  • There are indwelling catheters (tunneled ports, Hickman lines) which are more permanent central venous access devices used in patients with need for intermittent ventral venous access, typically placed by IR or surgery

Arterial Lines

  • Indications: accurate blood pressure measurement, frequent arterial blood draws (ABG)
  • Potential complications: arterial occlusion (spasm, thrombus), with resultant ischemia, hematoma formation
  • Criteria for removal: resolution of placement criteria

Feeding Tubes

  • Described in further detail below.
  • Placement: We can place dobhoff tubes or replace mature G-tubes
  • Troubleshooting: EGS consult for malposition/not functioning, wound consult for skin breakdown
  • G-tube study: 30mL Gastrograffin via tube [resident often must push] and KUB