RDGR tubes

Question 1

Why do we have endotracheal tubes?

Answer 1

• assist ventilation
• Airway control
• Prevents air from going into stomach
• Route for suctioning
• Medication administration

Question 2

Where is the placement for endotracheal tubes?

Answer 2

• tip should be 3-5 cm from carina (T5,T6,T7) with neck in neutral position
• Cuff should fill not distend lumen of trachea

Question 3

What would neck flexion and extension cause for misplacement of endotracheal tube?

Answer 3

Flexion=may cause 2 cm of descent of ETT

Extension= may cause 2 cm of ascent of ETT

Question 4

What are some complications of the endotracheal tube?

Answer 4

• placement in right main bronchus

- Tip must be 3 cm distal to level of vocal cords so vocal cords are not damaged

Question 5

What might happen if the endotracheal tube is misplaced in the right main bronchus?

Answer 5

• Atelectasis of the non-aerated right upper lobe of left lung
• Right-sided pneumothorax

Question 6

Why do we do tracheostomy tubes?

Answer 6

• Airway obstruction at or above laynx
• Long-term intubation (more than 21 days)
• Airway obstruction during sleep apnea
• When paralysis of muscles affects respiration

Question 7

Where is the placement for tracheostomy tubes?

Answer 7

• Tip halfway between stoma and carina, aprrox T3
• Not affected by flexion/extension of neck
• Cuff should fill not distend lumen of trachea

Question 8

What are the potential complications for the tracheostomy tubes?

Answer 8

• Perforation of trachea
  (signs: pneumoediastinum, pneumothorax, subcutaneous, emphysema)
• Tracheal stenosis (long-term)

Question 9

Why do we do Central Venous Catheters?

Answer 9

• medication adminstration
• Central venous pressure
• Placement
• No radiopaque marker
• Inserted by subclavian or internal jugular vein route

Question 10

Where is the placement for central venous catheters?

Answer 10

• CVC should reach media end of clavicle and tip medial to anterior end of first rib before descending into superior vena cava. Otherwise, may indicate arterial placement
• Indentation of the cardiac contour marks the junction between the superior vena cava and the right atrium
• no kinks in catheter

Question 11

What are the complications of the CVC?

Answer 11

• Malpositioned with tip in the right atrium or internal jugular vein (subclavian approach)
• May proved inaccurate central venous pressure readings
• May produce cardiac arrhythmias if the right atrium
• Pneumothorax
• Vein perforation
• Sharp bend in catheter
• Subclavian artery placement rather than a vein

Question 12

why do we do Peripherally Inserted Central Catheters (PICC) : non-tunneled catheter?

Answer 12

-Long term venous access
Medication adminsitration
-Blood draws
-Blood transfusions

Question 13

Where is the placement for the PICC?

Answer 13

• tip in SVC ideally but may be placed in an axillary vein if necessary
• Arm vein accessed for placement

Question 14

What are the potential complications of the PICC?

Answer 14

• Tip may become malpositioned
• Thrombosis of line
• Site infection

Question 15

Why do we do Venous Access Ports (implanted Infusion Port) Port A-Cath?

Answer 15

• Long term venous access
• Medication administration
• Blood transfusions
• Blood draws

Question 16

Where is the placement for the Venous Access Ports?

Answer 16

• Port is surgically implanted under the skin on chest or upper arm
• Tip of the line is placed in superior vena cava
• Specially designed needle is required to access the port (Huber)

Question 17

what are the complications of Venous Access Ports?

Answer 17

• Tip may become malpositioned
• Thrombosis of line
• Site infection

Question 18

Why do we do Pulmonary Artery Catheters (Swan-Ganz Catheter)?

Answer 18

• Measure cardiac output
• right heart pressure and indirectly, left heart pressure
• May measure mixed venous oxygen saturation
• Helps differentiate cardiac from noncardiac pulmonary edema

Question 19

What is the placement for Swan-Ganz catheter?

Answer 19

• Inserted into the subclavian, internal or external jugular or femoral vein and advanced until the tip is in the right atrium. Inflation of the balloon with air causes the tip to float into the proximal right or left pulmonary artery
• Tip should be within 2 cm of hila
• catheters balloon is inflated only when pressure measurements are taken, then deflated

Question 20

What are the potential complications of the swab-ganz catheter?

Answer 20

• Pulmonary infarction from occlusion of pulmonary artery
• Confined perforation or pseudo aneurysm at tip of catheter
• Symptoms: hemoptysis

Question 21

Why do we do Tunneled catheters with external ends (Perma-Cath)?

Answer 21

• Long term
• Surgically placed under the skin, tissue secures line
• One or more lumens outside the body for access, different types and uses (medication administration, total paraenteral nurition (TPN), blood draws
• Tip in SVC

Question 22

What do hemodialysis lines (Raaf, Quinton) look like?

Answer 22

• Tunnelled

- Double-lumen, large bore

Question 23

What are the placements for hemodialysis lines (Raaf, quinton)?

Answer 23

• Have 2 lumens arranged coaxially inside a single catheter between the 2 ports
• Ports are usually colour coded
• Arterial port withdraws blood proximal to the venous port through which blood is returned to the patient
• Some catheters may have one port (arterial) in SVC and the other in the right atrium (venous)
• Right internal jugular is most often used for access
• Lowest incidence of clotting

Question 24

What are complications of Raaf-quinton hemodialysis?

Answer 24

• Pneumothorax
• malposition
• Perforation of the catheter tip
• Infection
• Thrombosis of the vein containing catheter
• Occlusion of the catheter

Question 25

Why do we do pleural drainage tubes?

Answer 25

- remove air or fluid from the pleural space - Radipaque marker at site of drainage hole - None of side holes ahould lie outside of chest wall - Work in any position, however for optimal drainage - Pneumothoax: anterior and superior placement - Pleural effusion: Posterior and inferior placement

Question 26

What are complications of pleural drainage tubes?

Answer 26

- malposition = inadequate drainage - If a side hole is outside of chest wall, it may cause inadequate emphysema - Bleeding caused by cutting of intercostal artery - laceration of liver or spleen - Rapid re-expansion of a collaspsed lung may lead to re-expansion pulmonary edema

Question 27

Why do we do pacemakers?

Answer 27

- Correct cardiac arrhythmias | - Electrically stimulates heart to maintain rate

Question 28

What is the placement for pacemakers?

Answer 28

- Pulse genrator (battery) usually implanted in left chest wall under the skin - May have one, two or three leads - One lead always located in the apex of right ventricle - Right ventricle projects to the left of the spine on the frontal projection and anterior on the lateral projection - second lead usually in right atrium - Third lead in coronary sinus - Leads should have a gentle curves

Question 29

What are the potential complications of pacemakers?

Answer 29

- Pneumothirax - Fracture of leads - Perforation of heart by leads (causes cardiac tamponade) - Leads lost contact with ventricular wall (patient may twist generator under skin and contact is lost (twiddlers syndrome) - *avoid abducting or elevating patients left arm for 24 hours (prevents dislodging pacemaker and leads)

Question 30

Why do we do automatic implantable cardiac defibrillators (AICDs)?

Answer 30

-prevent death from tachyarrhythmias

Question 31

What is the placement for AICDs?

Answer 31

- one electrode is placed in the superior vena cava, if present, the ventricle - No kinks - Wider more opaque segment of electrode than pacemaker leads

Question 32

What are potential complications for AICDs?

Answer 32

- Leads may migrate | - Meads may break

Question 33

Why do we do nasogastric Tubes (Salem Sump, Levin)?

Answer 33

- Short - term feeding - decompression (removal of air and gastric secretions) - Gastric sampling - Medication administration - Diagnostic procedures - Radipaque stripe breaks at a side hole, approx 10 cm from the tip

Question 34

What is the placement of the nasogadtric tubes (Salem Sump, Levin)?

Answer 34

-The tip and all side holes should extend 10 cm into the stomach beyond the esophagogastric (EG) junction (The EG junction is usally located where the left hemidiaphragm and left side of the thoracic spine meet (left cardiophrenic angle)

Question 35

What are potential complications of nasogastric tubes (Salem Sump, Levin)?

Answer 35

- Malpostioning (coiling in the esophagus) (inserted into trachea, most likely to enter right main stem bronchus) - Perforation of esophagus (rare) - Long-term indweling can caus gastro-esophageal reflux (GERD)

Question 36

Why do we have feeding tubes (Dobbhoff)?

Answer 36

Nutrition

Question 37

What is the positioning for feeding tube (Dobbhiff)?

Answer 37

- weighted end - Ideally in the duodenum - Reduces risk of aspiration - However, stomach placement is common