Catheters, Tubes and Drains, Oh My!

Transcription

1 Catheters, Tubes and Drains, Oh My! Grayslake Chicago Crestwood PremierVets.net One of the most common procedures performed in veterinary medicine Similar requirements as most patient procedures Cognitive knowledge Understanding principles (infection control, site selection, catheter type, etc) Psychomotor skill Hand-eye coordination Three strikes, your out Keep attune to patient s level of comfort and anxiety Failure to visualize or palpate, warrants a mini-cut down Catheter type Short vs long Catheter functions Large volume infusions Hyperosmolar infusions (diazepam, parenteral nutrition, etc.) Prolonged dwell times (daily procedures) Repeated phlebotomy Hemodynamic monitoring Site selection If you can see the vein, it can be catheterized Patient anatomy (breed, previous amputation, etc.) Patient condition (diarrhea, incontinence, wounds, fractures, head trauma, etc.) 1

2 Varieties Short catheters Typically placed in extremities Large bore, typically preferred under emergency circumstances Dwell time influenced by Catheter size Osmolality of infusate Swelling Proximal to tape, suggests phlebitis or dislodgement Distal to tape, suggests tape is too tight Varieties Central catheters CVC (jugular) Through-the-needle, over-the-needle, seldinger techniques Single or multi-lumen Contraindications Head trauma, glaucoma, hyper- or hypo- coagulability PICC (peripherally inserted central catheters) Single or multi-lumen Contraindications Hypercoagulability Complications Catheter Related Blood Stream Infection (CR-BSI) Most cases cannot be traced back to one specific event More commonly viewed as resulting from the cumulative exposure to a series of known, potential risk factors. Risk factors are categorized into the two phases of catheter care: Insertion Daily maintenance Hemorrhage or thrombosis Foreign bodies Stylet Catheter 2

3 Catheter Insertion Supplies collected to common location (catheter tote, cart, etc) Patient on table Anti-sepsis Using CLEAN clipper blades Designated clippers with clippercide Brushes vs compressed air Wash hands +/- wear gloves 2% chlorhexidine scrub preferred over povidone iodine Don t touch site following scrub Clip wide, don t touch catheter to hair Catheter type Each lumen contributes to risk of infection Catheter maintenance Infusate Preparation Priming line Additives Injections Catheter maintenance Limit frequency of access Weigh when walking, etc. Avoid unnecessary disconnects Nurse:patient ratios Hurried providers by-passing standard precautions Hand washing, wiping injection ports with alcohol Avoid touch contamination Keep catheters and hubs protected Vomit, drool, urine, stool 3

4 Catheter maintenance Catheter security prevent motion Use CLEAN tape Change dressing if wet or soiled Avoid unnecessarily prolonged dwell times Evaluate catheters daily Scheduled rotations no longer advised Urinary Catheters Intermittent vs indwelling Indications Intermittent Urine / mass sampling Temporary bladder decompression recumbency, etc. Indwelling Urinary retention (neurogenic) Pre/intra/post-operative drainage of urine (calculi, mass, etc.) Epidural catheter (opioids) Quantitative urine output Protect open wound if incontinent Provide comfort care in terminally ill Urinary Catheters Catheter-Associated Urinary Tract Infection Risk factors Prolonged dwell time Female gender Comorbidities (DM, hyperadrenocorticism, renal insufficiency, coexisting infection, etc.) Fecal incontinence Faulty aseptic management of catheter or collection bag 4

5 Urinary Catheters Catheter-Associated Urinary Tract Infection Preventative measures Liberal clipping, thorough skin preparation and sterile gloves Meticulous handling of indwelling catheter and system USE CLOSED COLLECTION SYSTEM Keep bag below patient Limit unnecessary disconnects Limit dwell time Biofilm formation Urinary Catheters Additional Complications Antibiotic resistant CA-UTI Avoid antibiotic use during dwell period Biofilm formation Urethritis / spasms Use soft catheter materials argyle, red rubbers Use smallest bore catheter to achieve results Premature removal Urethral tear / bladder rupture Miscellaneous Catheter Items Ointments for IV catheter sites not indicated Benefits of antibiotic or silver sulfadiazine impregnated catheters remain uncertain Heparinization of IV flushes are not necessary Use sterile water for foley bulb inflation 5

6 Nasal Feeding Tubes Indications Provide nutrition for up to 2-3 weeks Gastric decompression Parvoviral enteritis Gastrointestinal obstructions Contraindications Nasal pathology / cribiform plate trauma Thrombocytopenia / thrombocytopathy / hypocoagulability Head trauma Sneezing Nasal Feeding Tubes Complications Incorrect placement Precautions Provide sedation Cervical ventroflexion during placement Use stylet Placement assessment Radiograph confirmation Positive gastric juice Infuse small volume of test water, before feeding Nasal Feeding Tubes Complications Premature removal Oropharyngeal Most common with vomiting Precautions Suction PRIOR to feeding Complete Precautions Maintain Elizabethan collar Secure to nasal philtrum Secure to tape collar 6

7 Nasal Feeding Tubes Complications Clogging Only infuse commercial liquid diets Flush after feedings Infuse only medications that are SOLUTIONS Epistaxis Sneezing Esophagostomy Tubes Indications Provide nutrition for months, if necessary Administer gruel food More economical Requires anesthesia Never need/use stylet Secure to periosteum of atlas Nasal Oxygen Tubes Indications Increase FiO 2 Patients experiencing hypoxemia Contraindications Same as nasal feeding tubes Nasal pathology / cribiform plate trauma Thrombocytopenia / thrombocytopathy / hypocoagulability Head trauma Sneezing 7

8 Nasal Oxygen Tubes Varieties Nasal Medial canthus Nasopharyngeal Lateral canthus Nasotracheal 3 rd to 4 th rib space The further caudal the tube tip, the higher the FiO 2 that can be achieved Flow rates of ml/kg Nasal Oxygen Tubes Complications Premature removal Sneezing nasal tubes Misidentified as a feeding tube Distinct and consistent attachment compared to nasal feeding tubes Accidental disconnects Jet lesions Nasal Oxygen Tubes Precautions Place nasopharyngeal instead of nasal Maintain Elizabethan collar Secure to nasal philtrum Secure to tape collar Secure all connections with white tape 8

9 Endotracheal Tubes Most intubations are routine Can use stylet (most commonly a polypropylene tube) if difficult Pre-oxygenation should be considered, unless patient is moribund or needs immediate intubation Use of a laryngoscope should be routinely practiced Modified sellick manuever Can be used if inappropriate fasting Endotracheal Tubes Placement confirmation 5 ations Visualization - epiglottis Palpation one vs two tubes Observation thoracic wall excursions Auscultation lung sounds in each hemithorax Condensation humidification noted inside tube ETCO 2 If spontaneous circulation is present Wound drains Penrose Passive drain Jackson-Pratt Active drain Increased risk of infection Resistance Increased environmental contamination Should be covered Dual-fold Minimizes risk of infection Allows for quantification of discharge Allows for microscopic evaluation of exudate Can be covered to prevent removal 9