dropped lung during central line

RedCell · Nov 16, 2008

Big needle punctures cavity relying on negative pressure. The lung collapses as air is entrained into the plueral space.

Guest219794 · Nov 17, 2008

As in during the initial insertion, missing the vein?

On the same line, any thoughts on using a ctrl line prior to xray?

hhern

RedCell · Nov 17, 2008

As in during the initial insertion, missing the vein?
On the same line, any thoughts on using a ctrl line prior to xray?
hhern

I assume you mean subclavian insertions as these carry a higher incidence of pneumo than IJs do. With subclavians your insertion site is just below the last 1/3 of the clavicle aiming for the sternal notch. The needle insertion is shallow and if your approach is too deep, or if the anatomy sucks, you can sometimes hit the cupola or the apex of the lung. IJ's carry a risk of pneumos too but are far less common again, due to needle insertion site. I have placed quite a few subclavians and IJs in school and have yet to obtain a CXR prior to using them because venous blood return is always confirmed with manometry prior to dilating the vessel. We do routinely order CXRs when the patient gets to the ICU or PACU.

neneRN, BSN, RN · Nov 20, 2008

We ALWAYS order a CXR before we can use the line...

Guest219794 · Nov 20, 2008

Why? Not saying it is bad, but since one person always gets a cxr, and one never gets a cxr there is obviously some variation in practice.

So- Assuming you have good blood return, what is the problem using the line?

hherrn

Dinith88 · Nov 20, 2008

Why? Not saying it is bad, but since one person always gets a cxr, and one never gets a cxr there is obviously some variation in practice.
So- Assuming you have good blood return, what is the problem using the line?
hherrn

The catheter tip could be projecting upwards (toward the brain) rather than downward toward the SVC/RA (especially true of subclavian lines)-in which case you shouldnt use the line. This is obviously less likely in IJ placement but CXR is still needed to r/o pneumo.

As far as your statement about some central-lines not getting CXR, all subclavian and IJ lines require CXR. If not...very poor medical practice...and unlikely (or oversight).

Guest219794 · Nov 20, 2008

Actually, the question was on using the line prior to a cxr. the cxr confirms placement, as well as ruling out a pneumo. So- regarding the hazards of using the line prior to a CXR:

The catheter tip could be projecting upwards (toward the brain) rather than downward toward the SVC/RA (especially true of subclavian lines)-in which case you shouldnt use the line.

This was not a hazard I was aware of. Can you elaborate? What path does the line take, and how does it end up in this position.

BTW- I would see not getting a CXR to be a nursing error, whether the doc ordered it or not.

hhern

Dinith88 · Nov 21, 2008

Actually, the question was on using the line prior to a cxr. the cxr confirms placement, as well as ruling out a pneumo. So- regarding the hazards of using the line prior to a CXR:
The catheter tip could be projecting upwards (toward the brain) rather than downward toward the SVC/RA (especially true of subclavian lines)-in which case you shouldnt use the line.
This was not a hazard I was aware of. Can you elaborate? What path does the line take, and how does it end up in this position.
BTW- I would see not getting a CXR to be a nursing error, whether the doc ordered it or not.
hhern

so...when you 'confirm placement' with an x-ray (as you mentioned) this is one of the things you look for. Normally the line will thread nicely into the SVC (superior vena cava) and the tip will (ideally) sit just above or slightly into the rt atrium. Sometimes, however, the catheter will migrate/advance into a jugular vein and (put simply) go up instead of down...the tip projecting up into the neck toward the head. This, in and of itself, isnt necessarily a bad thing....BUT...if you then use the line to dump volume...or give vasoactive drugs, TPN, etc, it can potentially cause serious problems...obviously. This is one aspect of 'checking placement'...along with ruling out pneumos, etc.

And i completely agree with you...a competent nurse will ensure the CXR is taken...but ultimately would fall on the doc if complications occur (pneumo, etc) and a film wasnt ordered (at least in a court of law).

fins · Nov 21, 2008

I've had it happen three times - twice on the same patient. Never use a central line before the chest x-ray is read.