CentralVenousCatheters.pdf

Central Venous CathetersIn Adult Patients Self Learning Module Fraser Health Vascular Access Regional Shared Work Team Patty Hignell, RN, BSN, MN, ENC(C) July 2011 – Version 7 Adapted from SMH Education Services SLP (2006) & Simon Fraser Health Region SLP (2000) TABLE OF CONTENTS INTRODUCTION ....................................................................................................3 WHAT IS A CENTRAL VENOUS CATHETER?....................................................................5 INDICATIONS FOR USE ......................................................................................................................... 5 WHERE ARE CVCS INSERTED? .................................................................................................................. 6 TYPES OF CENTRAL VENOUS CATHETERS ......................................................................7 SINGLE LUMEN VS. MULTI-LUMEN ............................................................................................................. 9 OPEN-ENDED OR CLOSED-ENDED (VALVED) ..................................................................................................... 9 HOW THE NEGATIVE PRESSURE (GROSHONG®) VALVE WORKS ................................................................................. 10 SHORT-TERM (PERCUTANEOUS) CATHETERS ................................................................ 13 SUGGESTED LUMEN CHOICE FOR INFUSIONS .................................................................................................. 16 HEMODIALYSIS CATHETERS ................................................................................... 17 NURSING CARE: PRE/POST INSERTION OF SHORT-TERM CATHETERS ................................. 18 PERIPHERALLY INSERTED CENTRAL CATHETERS (PICC) .................................................... 23 TUNNELED CATHETERS ......................................................................................... 29 IMPLANTABLE VENOUS ACCESS DEVICE (IVAD)............................................................. 35 COMPLICATIONS ASSOCIATED WITH CVCS ................................................................. 44 AIR EMBOLISM.............................................................................................................................. 45 INFECTION.................................................................................................................................. 46 OCCLUSIONS ................................................................................................................................ 47 COMPLICATIONS AND NURSING ACTIONS ............................................................................................. 49 CARE AND MAINTENANCE OF CVCS........................................................................... 54 MEDICATIONS AND TUBING .............................................................................................................. 55 POSITIVE DISPLACEMENT CAPS .......................................................................................................... 55 CLAMPS ...................................................................................................................................... 56 FLUSHING ................................................................................................................................... 56 FLUSH ROUTINES - ADULT ................................................................................................................. 57 DRESSINGS.................................................................................................................................. 57 BLOOD SAMPLING .......................................................................................................................... 58 PATIENT POSTIONING FOR CARE AND MAINTENANCE ............................................................................... 59 REMOVAL OF SHORT-TERM CVC AND PICCS ............................................................................................. 60 INFECTION CONTROL...................................................................................................................... 62 TROUBLESHOOTING A BLOCKED CATHETER............................................................................................. 63 MONITORING CENTRAL VENOUS PRESSURE (CVP) ..................................................................................... 63 REPORTABLE CONDITIONS ................................................................................................................ 64 REFERENCES ...................................................................................................... 67 APPENDICES....................................................................................................... 70 APPENDIX APPENDIX APPENDIX APPENDIX A: RESPONSIBILITY FOR CVC MANAGEMENT .............................................................................. 71 B: CENTRAL VENOUS CATHETER INSERTION AND REMOVAL FORM ................................................................ 72 C: WEEKLY IV/CVC MAINTENANCE WORKSHEET (EXAMPLE) ...................................................................... 73 E: CENTRAL VENOUS CATHETER (CVC) SKILLS INVENTORY ....................................................................... 74 2 INTRODUCTION The use of Central Venous Catheters (CVCs) has increased dramatically over recent years. Once seen only in critical care areas, these catheters are now commonplace in the medical/surgical and community environment. Depending on the patients needs, there are a variety of central lines available. A CVC can be inserted for short-term or long-term I.V. therapy. Central Venous Catheter management requires evidence-based, best practice standards to minimize complications and maximize patient outcomes. CVC management is a specialized skill performed by IV practitioners who have demonstrated the required competencies. PURPOSE This self-learning module will provide you: ♦ Information about CVCs ♦ Information about nursing care and management of CVCs in the adult patient This self-learning module along with return skill demonstration will assist you in meeting the competencies of CVC management. ♦ Please see Appendix A (Responsibility for CVC management) LEARNING INSTRUCTIONS The learning activities in this self-learning module are based on the objectives and will help you to understand and apply what you have learned. It is recommended that you complete the learning activity after each section. If you are using this self-learning module for the purpose of review, you may wish to attempt the learning activities first to find out what material you need to review. 3 ♦ List safety considerations when caring for a patient with a CVC. insertion and post-insertion for percutaneous. ♦ List advantages and disadvantages for a percutaneous. and provide the rationale Let’s get started…… 4 . tunneled and implantable CVCs. ♦ List possible complications of CVCs and the nursing actions for each complication.OBJECTIVES Upon completion of this module the learner will be able to: ♦ Define “central venous catheters” ♦ Identify types of CVCs and indications for use ♦ Describe the nursing care and maintenance of CVCs ♦ Describe and identify complications associated with CVCs ♦ Identify common insertion sites ♦ Describe the difference between open-ended and closed-ended (valved) catheters ♦ Identify the nursing responsibilities for pre-insertion. tunneled and implanted CVC. and solutions with extreme pH values (i. Indications for Use ♦ Administer intravenous fluids and blood products ♦ Administer medications ♦ Administer hypertonic solutions (Total Parental Nutrition [TPN]).e. Dopamine) ♦ Monitor central venous pressure (CVP) ♦ Provide access for transvenous pacemaker or pulmonary artery catheters ♦ Access venous circulation when a patient has difficult or impossible peripheral access ♦ Provide hemodialysis access 5 . the continuation below that point being considered part of the heart. ♦ Obtain venous blood samples ♦ Provide long term intravenous therapy ♦ Administer large volumes of intravenous fluid quickly ♦ Administer vasopressor or vasodilator therapy (e.chemotherapy). All CVCs placed for the purpose of venous access and being inserted in the upper body will ideally have the tip placed within the superior vena cava at or just above the Cavo-Atrial junction.e. vesicants (i. ♦ Femorally inserted CVCs have the tip lying in the Inferior Vena Cava approximately at the level of the diaphragm.e. ♦ The tip of the CVC usually rests in the Cavo-Atrial Junction (CAJ).What is a Central Venous Catheter? ♦ A Central Venous Catheter (CVC) is an indwelling intravenous device that is inserted into a vein of the central vasculature.cloxacillin). irritants (i.g.vancomycin). This junction marks the inferior end of the superior vena cava (SVC). WHERE ARE CENTRAL VENOUS CATHETERS INSERTED? The Neck/Upper Chest >Internal jugular vein >External jugular vein >Subclavian vein The Arm > > > Brachial vein Cephalic vein Basilic vein The Groin > Femoral vein 6 . Types of Central Venous Catheters 7 . e. Short term or Long term) ♦ Complex or unusual vascular anatomy ♦ Previous devices and complications ♦ Clinical diagnosis and assessment ♦ Clinical situation ♦ Care setting ♦ Patient/family preference ♦ What alternatives are there? ♦ Always advocate for Best Practice! 8 . Non-Tunneled.Types of Central Venous Catheters ♦ Short-term (Percutaneous. Non-Cuffed) Short Term ♦ PICC (Peripherally Inserted Central Catheters) Long Term ♦ Tunneled Catheters Long Term ♦ Implanted Venous Access Devices (IVAD) Long Term COMPOSITION ♦ Polyurethane or Silicone COATINGS ♦ May have antimicrobial or antiseptic coating to protect against bacterial seeding ♦ May have heparin coating to reduce fibrin formation ♦ Radiopaque to confirm tip placement by X-ray The type of CVC inserted depends on the: ♦ Type of therapy to be administered ♦ Length of therapy (i. PAS-V®) ♦ Clamping is not required as the valve is closed except during infusion or aspiration ♦ May be present on Tunneled Catheters. Multi-lumen ♦ ♦ ♦ ♦ Single. (In a triple lumen catheter. the Medial lumen is typically used) Center Venous Catheters: Open-ended or Closed-ended Open–ended ♦ The catheter is open at the distal tip ♦ The catheter requires clamping before entry into the system ♦ Clamps are usually built into the catheter ♦ Requires periodic flushing ♦ Any type of CVC can be open-ended Closed-ended ♦ A valve is present at the tip of the catheter (eg. double and triple lumen catheters are available in all catheter types Each lumen must be treated as a separate catheter Incompatible medications can be infused simultaneously via separate lumens Exit ports are approximately 2cms apart on the short-term catheter When TPN is being infused a lumen MUST be dedicated and labeled for this use.Central Venous Catheters: Single Lumen vs. Groshong®) or at the hub of the catheter (eg. Nothing else is to be given via that lumen. Implanted Ports and PICCs 9 . y The valve works when pressure is applied to it. • Example of a closed-ended catheter with a pressure-activated safety valve (PASV) in the hub of the catheter: Power PICC Solo® BARD Medical© 10 . the valve opens inward and blood flows into the syringe. With no pressure the valve remains closed.How the Negative Pressure (Groshong®) Valve Works When negative pressure (suction) is applied. y When positive pressure is applied (fluid infusion or flush) the valve opens outward and fluid enters the bloodstream. c. D. B. it is important to know catheter type. and tip location 11 . design (open–ended or closed–ended). a b. clamping is _____ required as the valve is ____ except during infusion or aspiration. c a. d all of the above 2) Uses for a CVC include which of the following? a) TPN administration b) IV drug and fluid administration c) Blood product d) Blood sampling e) Measurement and monitoring of Central Venous Pressure f) All of the above 3) List four types of CVCs a) _____________ b) _____________ c) _____________ d) _____________ 4) Open-ended CVC’s requires clamping? T or F? 5) With a Closed-ended CVC. C.Test your Learning 1) Which of the following would not be considered a CVC? A catheter placed: a) in the radial artery b) in the superior vena cava c) so its tip is at the junction between the superior vena cava and the radial artery d) with its tip in the external jugular vein A. For all CVC’s. 12 . Tunneled. Closed Congratulations! You have just completed the first section. and IVAD 4) True 5) Not.Answers 1) C 2) F 3) Short Term. PICC. Let’s keep moving….. Short-Term Catheters 13 . Short-Term Catheters A short-term catheter is inserted directly into a large central vein through the skin. a pacemaker wire.5F sizes Obturator must be in place to seal the diaphragm when the catheter is not being used as an introducer for a Pulmonary Artery Catheter. These catheters may be single or multi lumen. Comes in 7 and 8.lumen CVC. Some are sutured in place at the insertion site. or a multi. Examples of Short-Term Catheters: ♦ ♦ ♦ ♦ ♦ Single lumen short-term CVC Multi-lumen short-term CVC Percutaneous introducer Femoral CVC Temporary hemodialysis catheter SINGLE LUMEN SHORT-TERM CVCs a) Single Lumen without pigtail (must add clampable extension tubing) b) Single Lumen with pigtail c) Single Lumen with side port or Percutaneous Introducer. ***Found in Critical Care Areas ONLY*** 14 . e. double. or triple lumen Adult or pediatric sizes Can be used for blood sampling Economic.: pneumothorax. but may be left in as long as the catheter is needed. if it is still functional and not a source of infection ♦ Emergency access ADVANTAGES • • • • • • All types of therapies can be administered Preserves peripheral veins Can be single. Consider referral for insertion of long-term CVC if it will be needed for >14 days Firm catheter may erode the vessel Can be easily dislodged 15 .MULTI-LUMEN SHORT-TERM CVCs a) Percutaneous Introducer Sheath b) Triple lumen Cross-section Proximal Lumen Medial Lumen Distal Lumen USES SHORT-TERM OPEN-ENDED CATHETERS ♦ Short term use. quick placement DISADVANTAGES • • • • • • HIGHEST risk for infection Not for home intravenous therapy Greater risk of insertion and post insertion complications (i. air embolism) Not to be used long term. P. X1 X1 or X2 Medication Administration X X3 X X3 X3 Blood Sampling X X3 X X X CVP Monitoring X X X1 .Suggested Lumen Choice for Infusions via Multi-lumen Short-Term Catheters INTRODUCER WITH SINGLE LUMEN ADAPTER FUNCTIONS PROXIMAL 18 gauge MEDIAL 18 gauge DISTAL 16 gauge SIDEARM SINGLE LUMEN (CVP) IV Fluid Administration X X3 X X X Blood or Colloid Administration X X3 X X X X X X Rapid IV/Blood Replacement T. W ICH H UB D O Y OU S CRUB? WH HICH HUB DO YOU SCRUB? • Friction scrub the Positive Displacement IV Cap when accessing through the cap • Friction scrub the CVC hub when removing/changing cap • Always scrub using an alcohol swab for 30 seconds allow to dry completely 16 .N.used for TPN when CVP Monitoring is not required and blood sampling from Side Arm is required. X2 . X3 .preferred unless blood sampling will be required from this lumen.Lumen is not used for medication administration while TPN is infusing. ♦ HD lines may be accessed by Critical Care Nurses in a Code or Trauma situation ♦ HD lines are central catheters/ Maintain aseptic technique as they are the patient’s life lines.9% 10 mL pre-filled syringe for a total of 20 mL per lumen. ♦ Once patient stabilizes please plan for use of an alternative access.HEMODIALYSIS CATHETERS ♦ A hemodialysis catheter is a type of Central Venous Catheter used for patients requiring hemodialysis.9% NaCl solution at 20 ml/hr. Reclamp. Attach a vacutainer or syringe. unclamp and take blood samples. ♦ The Renal Program has specific policies and procedures related to these catheters. Infusing Medication/IV infusion ♦ Clamp. After use flush catheter with 20ml NaCl 0. run an IV 0. unclamp and withdraw 5 mL locking agent. A Renal Nurse must flush and re-cap the catheter after the dialysis line has been accessed. The lumens of these catheters are larger allowing for large volumes of blood to be processed and returned to the patient.9%. ♦ Catheter ports must never be left unattended and open to air. ♦ If there are problems with withdrawing from a lumen do not push locking agent or clot into the patient. ♦ Once you are finished. The line can be used for: o blood samples o infusing a medication o IV infusion Procedure: ♦ Place patient supine ♦ Create a sterile field/ Don sterile gloves/mask ♦ Ensure both clamps closed ♦ Clean Tego™ connector hub with alcohol swab and leave to dry ♦ Attach a 10 mL luer syringe. 17 . Attach solution tubing Blood samples ♦ Withdraw 10ml discard from the lumen. Discard syringe. Notify the Renal Unit that the dialysis line has been accessed. and discard ♦ Using a second 10 mL syringe withdraw and instill blood 2-3 times (ensures locking agent is cleared) ♦ Flush line with the NaCL 0. clamp and discard. and sterile gloves. and sounds o Place patient in Trendelenberg position to dilate the veins and reduce the risk of air embolism if tolerated. must wear a mask. Use of maximum barrier precautions: • o The patient is covered from head to toe with a sterile drape with a small opening for the insertion site (to observe/monitor the patient’s head area. such as those without direct contact. o The assisting practitioner must hand wash and use a surgical cap (bouffant cap). hand wash to remove visible dirt (soap and water or 2% Chlorhexidine). its benefits and what might be expected of the patient during and after insertion (Physician responsibility) o Assess patient’s vital signs and document. o The inserting practitioner must remove jewellery. Some patients are unable to tolerate this position. 18 .NURSING CARE: PRE/POST INSERTION OF SHORT-TERM CATHETERS Short term CVCs may be inserted on the Nursing Unit. sterile gown. wear eye protection. subsequent hand washing before and after palpating catheter insertion site (alcohol gel is sufficient). depth. As a Nurse. sterile gown. you may be asked to assist the Physician with insertion. and sterile gloves. mask. consider placing a mayo stand under the drape in this area). or Emergency. and use a surgical cap (bouffant cap). symmetry. mask. o Perform a respiratory assessment including breathing patterns. When this occurs follow the Physician’s direction. Key Points to Remember: Pre-Insertion: • o Prior to insertion ensure the patient/family understands the procedure. in the Operating Room. in Medical Imaging under fluoroscopy. o Other personnel. Preparation .Completion of chest x-ray . draw blood gas from the femoral CVC and send sample to Lab to ensure the results are a venous sample (Venous Blood Gases).Amount of infused solution .Placement confirmation On CVC Weekly Maintenance Worksheet: o .RN who assisted with the insertion .Type of IV solution Multi-disciplinary Progress Notes - Appearance of the entrance site Patient tolerance of procedure Post-insertion patient assessment 19 .Initial complications . o Ensure that all lumens are flushed with 20 mL of NS immediately after insertion. To confirm correct placement in vein.Insertion procedure .Post-insertion • o o Order a portable chest x-ray for Physician to confirm correct placement of line NOTE: Do not use CVC until confirmation of placement received by Radiologist or Physician unless condition warrants need for immediate infusion of large volume of fluid.Type of catheter .Date routine flushes are due .Physician who inserted the line and their initials .Patency Assessment .Date IV cap and/or tubing changes are due .If a transparent dressing was applied . o FEMORAL SITE: If a Short-term CVC is inserted into a femoral site – no chest x-ray required.How the catheter was secured .Date & time .The nature of the insertion . o Monitor patient vital signs every 30 min x 2 Documentation • o Documentation to be done on the Central Venous Catheter Insertion and Removal Form (see Appendix B) including: o .How much of the catheter is showing above the insertion site (in centimetres) On Fluid Balance Record: o .Vein used . In Critical Care areas. transduce the femoral CVC and ensure you have an appropriate CVP waveform.Daily need for CVC reviewed . Assessment is done post-insertion of a short-term CVC Q____min x ____. List two responsibilities of the primary nurse post-insertion of a multi-lumen catheter? 6. 4. Post-insertion. check for signs of: a) _______________ b) _______________ c) _______________ d) _______________ 20 . Short-Term catheters are inserted ___________into a ___________ through the _____________________. Short-term catheters are ________ ended. 2. Short-term catheters have the ___________ rate of infection. 3. What position is the patient placed in for a short-term catheter insertion? _____________________________ 5. 7.Test your Learning 1. 21 . Q30min x 2 7. skin 2. Trendelenberg 5. - Ensure that all lumens of a CVC are flushed with 20 mL of NS post-insertion - Document - Post-insertion assessment and vital signs 6. - Order a portable chest x-ray for physician to confirm correct placement of line. a) b) c) d) Subcutaneous emphysema Bleeding Air embolus Pneumothorax Congratulations! You have just completed the second section. Let’s keep moving….. open 4. highest 3.Answers 1. vein. directly. 22 . Peripherally Inserted Central Catheters 23 . • The tip rests in the superior vena cava at the cavo-atrial junction. • PICCs are chosen for patients requiring IV therapy for more than six days and up to one year. 24 .Peripherally Inserted Central Catheter (PICC) • Venous access is obtained by puncturing the brachial. but may be individually sized upon insertion. or basilic vein just above or below the antecubital fossa. • The catheters are approximately 40-60 cm long. cephalic. Check Parenteral Drug Therapy Manual prior to use PRE-INSERTION ♦ Administer a sedative prn as ordered prior to the pre-scheduled procedure time ♦ Ensure the order entry for chest x-ray for PICC tip position has been placed into MediTech Order Entry ♦ Ensure the patient is in Ambulatory/General Day Care department 15 minutes prior to scheduled time (if applicable) Insertion ♦ Insertion of PICC catheters is done by Advanced Competency Assessed RNs who have received special training. Home IV team) Can remain in place for several weeks to a year Easily removed by a Competency Assessed RN PICCs eliminate the risks associated with neck. chest & femoral insertion Low infection rate External portion can be repaired DISADVANTAGES • • • • • Requires a dressing & frequent assessments External device Some PICCs (small gauge) not recommended for blood sampling Not ideal for rapid infusions Not recommended route for some medications (i. tenderness ♦ Q1hr: Monitor site patency and rate of IV infusion Removal – See Removal of Short-Term CVCs and PICCs pg.phenytoin). radical neck dissection or radiation therapy to chest.USES Peripherally Inserted Central Catheter • • ADVANTAGES Intended for days to several weeks to months of IV access Peripheral insertion may be needed for patients with chest injuries. These RNs are usually located in the Ambulatory/General Daycare department and/or are a Home/Community IV RN Post-Insertion ♦ Prior to using the PICC catheter : ¾ Ensure placement has been confirmed by x-ray ¾ Ensure order had been received from the physician ♦ May apply warm compress to arm above PICC venipuncture site QID x 20 minutes for 3 days PRN (to prevent mechanical phlebitis) ♦ Do not take blood pressures or venipuncture the arm with a PICC or PAS-V port inserted.e. • • • • • • PICCs are inserted by Advanced Competency Assessed RNs (i.e. 57 25 . ♦ Monitor for swelling. PICCs can remain in place for__________________________ (time period). ensure a ___________ _____________has been done to confirm placement. PICC catheters are approximately ____________ cm in length.Test Your Learning 1. Pre-insertion administer __________ as ordered prior to insertion.) List 2 disadvantages of PICC lines a) ________________________ b) ________________________ 5. 7. List two things you should not take from the arm where the PICC is inserted: a)____________ b)____________ 26 . 6. Post –insertion prior to using the PICC. 9. 2. 8. Apply warm compresses to arm above PICC site Q______ X ______minutes for 3 days PRN. List 2 advantages of PICC lines a) _________________________ b) _________________________ 4. The tip of a PICC rests in the: a) radial artery b) jugular vein c) superior vena cava at the junction of the right atrium d) femoral artery at the junction of the right atrium 3. sedative 7. chest & femoral insertion.Answers 1. 40-60 cm long 6. blood pressure b. Can remain in place for several weeks/ months. the external portion can be repaired. venipuncture Congratulations! You have just completed the Third section. difficult for self-care 5. 27 . PICCs are inserted by Home IV RN. easily removed by the Competency Assessed RN. PICCs eliminate the risks associated with neck. x-ray 8. 4. QID X 20 minutes 9 a. external device.. some PICCs (small gauge) not recommended for blood sampling. Requires a dressing & frequent assessments. lower rates of infection. C 3. Let’s keep moving…. six days and up to one year 2. 28 . TUNNELED CATHETERS 29 . ♦ Examples of Tunneled Catheters are Hickmans®.Tunneled Catheters ♦ A tunneled catheter is a long-term catheter (lasting months to years) that exits the skin via a subcutaneous tunnel. ♦ A Dacron cuff on the tunneled portion of the catheter facilitates anchoring of the catheter through granulation and acts as a barrier to infection. blockage or thrombosis) External portion can be repaired Self-care by patient Once site healed. Broviac® and permanent hemodialysis catheters (eg. or triple lumen. ♦ Tunneled catheters may be single. CUFFS USES Tunneled Catheters Used for long-term intermittent or continuous access for: • Medication administration (including vesicants) • Parenteral nutrition • Blood/blood product administration and sampling • Hemodialysis ADVANTAGES • • • • Can be left in place indefinitely (if no infection. no dressing is needed at home DISADVANTAGES • • • • Inserted in the OR or Medical Imaging under Fluoroscopy Requires a dressing & frequent assessments External device Physician must remove 30 . double. Perm-Cath®). the surgeon selects the exit site. provide an opportunity for the patient to see pictures. INSERTION PROCEDURE ♦ This procedure is performed in the Operating Room or Interventional Radiology under sterile technique ♦ The patient is placed in Trendelenberg position to dilate the veins and reduce the risk of air embolism ♦ The surgeon accesses the subclavian vein using a percutaneous approach and inserts the central venous catheter over a guide wire. ♦ Perform baseline vital sign assessment.NURSING CARE PRE/POST INSERTION OF TUNNELED CATHETERS Tunneled catheters may be inserted in the Operating Room under a local anaesthetic or in Radiology under fluoroscopy. ♦ If possible. assessment. Once the catheter is placed in the appropriate vein and the guide wire has been removed. and handle a demo catheter. which are part of the catheter and sit 3 5 inches above the skin exit site. benefits and risk of procedure. Catheters are typically tunneled for several inches (4-6”) from the location where they enter the vein and usually exit the body midway between the nipple and the sternum. ♦ Discuss feelings about potential body image changes (external device). The Nurse’s role in the insertion of a tunneled catheter involves preinsertion teaching. PRE-INSERTION ♦ Ensure patient/family understands reasons for insertion. and post-operative site care. ♦ Most tunneled catheters have one or two cuffs. The cuffs help to secure the catheter in place and reduce the potential for infection to travel through the tunnel. The surgeon then tunnels the catheter subcutaneously away from the insertion site. 31 . THESE PATIENTS WILL STILL NEED A DRESSING WHILE IN HOSPITAL TO PROTECT THEM FROM A NOSOCOMIAL INFECTION. ONCE THE INSERTION SITE IS HEALED. ♦ The person who has a tunneled catheter will have two dressings post-operatively: one at the insertion site and a second at the exit site. ONCE THE SITE HAS HEALED THIS WILL BE CHANGED TO A TRANSPARENT SEMI-PERMEABLE (TSM) DRESSING. The insertion site will have two to three sutures covered with a light dressing. or as per Physician’s Order. exit site after 14 days. HR and RR ¾ Respiratory assessment including: breathing patterns. depth. 32 .POST INSERTION OF TUNNELLED CATHETERS ♦ Post-Insertion and q30 minutes x 2: ¾ Vital signs: BP. symmetry and breath sounds ¾ Check for signs of: o Subcutaneous emphysema o Bleeding o Air embolus o Pneumothorax ¾ Ventilated patients: o Ensure ventilator system pressures are unchanged ¾ Cardiac monitored patients: o Observe for the occurrence of cardiac dysrhythmias ♦ Q1H: ¾ Monitor site patency and rate of IV infusion ¾ Sutures are usually removed from the entrance site after seven to ten days. THE EXIT SITE WILL ALSO HAVE A DRESSING. AFTER 3-6 WEEKS THEY MAY GO WITHOUT A DRESSING AT HOME. THE DRESSING AND SUTURES ARE REMOVED AND THE SITE IS LEFT UNCOVERED. The site may be a bit edematous and there may be a small amount of drainage. List some uses for tunneled catheters _________________________________________ _________________________________________ _________________________________________ 4. Once the insertion site is healed. Tunneled catheters may only be single or double lumen. What position should the patient be placed in for insertion and why? ____________________________________________________ 5. _________________________________ _________________________________ _________________________________ 6. List possible post insertion complications. T or F 2. the dressing and sutures are removed and the site is left uncovered.Test Your Learning 1. What are the 3 types of tunneled catheters? _________________________________________ _________________________________________ _________________________________________ 3. T or F 33 . The patient is placed in Trendelenberg position to dilate the veins and to reduce the risk of air embolism. bleeding. 4.ANSWERS 1. T Congratulations! You have just completed the Fourth section. double. Used for long-term intermittent or continuous access for medication administration. Let’s keep moving…. Subcutaneous emphysema. 34 .. or triple 2. hemodialysis. air embolus. PermCath®) 3. F. blood/blood product administration and sampling. Broviac® and permanent hemodialysis catheters (eg. single. Hickman®. pneumothorax 6. 5. parenteral nutrition. IMPLANTABLE VENOUS ACCESS DEVICE (IVAD) 35 . IMPLANTABLE VENOUS ACCESS DEVICE (IVAD) ♦ IVADs are long-term (months to years) single or dual chamber “port” surgically implanted in the subcutaneous tissue. Catheter .May be stainless steel. IVAD Components Portal body . Volume (of reservoir) is dependant on the size of the port and ranges from 0. ♦ Each chamber must be managed separately. functional. This procedure is done in the Operating Room or Interventional Radiology. usually in the upper chest. open-ended or close-ended 36 . titanium.Tip in SVC. ♦ A non-coring point needle is required to access the device (see pg 35).2-1. SafeStep®) Reservoir .Inside the port.Must only be accessed with a non-coring needle (i. or plastic May be single or double port Septum .5mL. a 5 mL of heparin 10 units/mL (dose to be administered 50 units) pre-filled syringe is used ♦ The surgical technique to place an IVAD is similar to that used to place a tunneled catheter. • When de-accessing an IVAD. and is not a source of sepsis.e.Self sealing silicone septum which may stay in as long as the device is required. Radiopaque. . IMPLANTABLE VENOUS ACCESS DEVICE (IVAD) BARD Power Port® Thoracic Placement Peripheral Placement 37 . 38 . and is not a source of sepsis.Non-Coring Needle (i. SafeStep® & SafeStep PowerLoc®) Remember to replace all caps that come with a non-coring needle set with positive displacement caps to prevent occlusions! USES Implantable Venous Access Devices ADVANTAGES Used for long-term intermittent or continuous access for: • Medication administration (including vesicants) • Parenteral nutrition • Blood/blood product administration and sampling • • • • • • • Internal device.e. DISADVANTAGES • • Needle access is required Surgical procedure required to insert/remove NURSING CARE: PRE/POST INSERTION PRE-INSERTION ♦ The nurse’s role in pre-insertion care includes patient education: > Provide information about the surgical insertion of an IVAD to the patient and family. > Female patients are sent with their bras to the OR/Medical Imaging to aid the surgeon with site selection. This is a shared responsibility between the Physician and the RN. functional. no dressing or site care Can be permanent Unrestricted activity Decreased risk of infection No external components to break Less body image impact May be used as long as the device is required. videotapes and demo catheters may be available at some sites for patient teaching. > Pamphlets. ♦ The entire procedure takes 30-60 minutes. ♦ The portal body is placed over a bony prominence (e. INSERTION ♦ IVADs are inserted in the OR/MI under a local anesthetic and sterile technique. it is recommended that it be done in the OR. the portal body is sutured to the fascia on all 4 sides with nonabsorbable sutures. ♦ The catheter is then positioned with the distal end positioned at the junction of the superior vena cava and the right atrium. cephalic. or jugular veins. HR and RR ¾ Respiratory assessment including: breathing patterns. swelling. to ensure easy palpation.g. Otherwise. Appropriate site selection is essential. This is to prevent it from twisting or moving. ♦ Once the site is selected. ♦ A cut down method is used and the catheter is introduced through a venotomy into the subclavian. device rotation and skin necrosis 39 . access occurs in approximately one week. infection. If early access is required. symmetry and breath sounds ¾ Check for signs of: o Subcutaneous emphysema o Bleeding o Air embolus o Pneumothorax Ventilated patients: ¾ Ensure ventilator system pressures are unchanged Cardiac monitored patients: ¾ Observe for the occurrence of cardiac dysrhythmias Q1H: ¾ Monitor site patency and rate of IV infusion ¾ The incision dressing may be removed when there is no evidence of drainage (unless otherwise directed by physician) ¾ Once healed if accessed. ribcage). When not accessed. The implantable ports can cause minor distortion of the MRI and other x-ray procedures. ♦ The port is flushed in the OR/MI. a transparent dressing is applied to the site and then the IVAD is treated as any other CVC. depth. IMPLANTABLE VENOUS ACCESS DEVICE (IVAD) ♦ Post-Insertion and q30 minutes x 2: ♦ ♦ ♦ ♦ ¾ Vital signs BP. Observe and document site condition including: ¾ Wound hematoma.> Advise the patient to carry identification of the port model and composition with them at all times. no dressing is required. usually in the ______________.¾ Slight edema and tenderness around the port implantation site is normal for the first few days post operatively and does not prevent use unless it is excessive ¾ Most Physicians prefer to wait a few days before accessing. Resistance may also be noted when attempting to infuse and swelling may occur at the site. stop using the port and notify the Physician to re-stabilize or re-insert the port. If this occurs. Name the four components of the IVAD. What type of needle is used to access the device? _______________ 3. Test your Learning 1. Each chamber must be managed separately. although this is not always possible if no other access routes are available “Twiddler’s Syndrome” occurs when a port is dislodged within the subcutaneous pocket because of trauma to the site or manipulation (twiddling) of the port by the patient. List two advantages of using IVADs. the port is noted to move easily under the skin. What is the role of the nurse for pre-insertion of an IVAD? 40 . 2. When this occurs. List two disadvantages of using IVADs. 1)______________________ 2)______________________ 6. T or F 4. IVADs are surgically placed in the ____________. 1)______________________ 2)______________________ 3)______________________ 4)______________________ 5. 1)______________________ 2)______________________ 7. ______________________________________________________________________ ____________________________________________________________________ 8. Post insertion assessment of IVAD is completed q ___ minutes x _____. 9. Monitor site patency and rate of IV infusion q ___. 10. Heparin is only used when _________________ an IVAD. Answers: 1. subcutaneous tissue, upper chest. 2. Non-coring or SafeStep® needle. 3. T 4. Portal body, Septum, Reservoir, Catheter 5. Internal device, no dressing or site care, can be permanent, unrestricted activity, decreased risk of infection, no external components to break, no body image impact, may be used as long as the device is required, functional, and is not a source of sepsis. 6. Needle access is required, surgical procedure required to insert/remove 7. Patient education 8. q 30 minutes, x 2 9. q 1 hour 10. De-accessing 41 Congratulations! You have just completed the fifth section. Let’s keep moving….. 42 43 Complications Associated With Central Venous Catheters 44 . It appears it is the speed with which air enters the system. To minimize the chance of air entering the system: Ensure the lumen is clamped prior to opening the system Keep a blue clamp or padded forcep with patient in case of catheter breakage Use Luer lock connections Having patient perform Valsalva maneuver (forcible exhalation against a closed glottis) when risk of air embolism is high ♦ Position the patient so that the insertion site is at or below the level of the heart during insertion and removal of catheter ♦ ♦ ♦ ♦ SIGNS AND SYMPTOMS OF AIR EMBOLI: ♦ CNS changes: altered neurological signs. the patient is at risk for the development of an air embolus. An AIR EMBOLISM is potentially the most deadly complication associated with CVC’s. Complications generally associated with the insertion procedure are: Cardiac Pneumothorax Bleeding Hematoma Dysrhythmias Hemothorax. dizziness. It can occur as the catheter is inserted.COMPLICATIONS ASSOCIATED WITH CENTRAL VENOUS CATHETERS ♦ Air Embolus ♦ Catheter Dislodgment ♦ Pulmonary embolus ♦ Infection ♦ Device Malfunction ♦ Venous Thrombosis ♦ Occlusion ♦ Perforation ♦ Catheter tip migration ♦ Extravasation ♦ Phlebitis ♦ Broken or damaged catheter tip Air Embolism. ♦ Respiratory changes: sudden shortness of breath. confusion. ↓BP. rather than the amount that increases the risk Anytime the central venous system is opened to atmospheric pressure. but the risk of air embolism is present as long as the catheter is in situ. loss of Consciousness ♦ CVS changes: sudden onset of chest pain. & Occlusion are the 3 most common complications. no BP. cyanosis 45 . and will be discussed in more detail below. ↑HR. Infection. (adapted from American Journal of Nursing.THE TREATMENT FOR AIR EMBOLISM INCLUDES: ♦ Positioning the patient on their left side in Trendelenberg (if not contraindicated by other conditions such as increased intracranial pressure or respiratory diseases) ♦ Clamp the Central Venous Catheter (between the patient and air if possible) ♦ Initiate cardiac and respiratory resuscitation measures as needed and notify the physician Further interventions by the physicians may be necessary to remove the air from the ventricle or the air may dissipate slowly on its own. The speed at which the air enters the body and patient positioning are more crucial factors than the actual amount of air in predicting morbidity from an air embolus. ♦ The literature suggests that common contaminating organisms are those which colonize the skin. 46 . from the exit site and into the accessed vein. ♦ The likely port of entry is still debated but it appears to be from openings in the IV system or at the catheter hub. ♦ Organisms may also track down the tunnel. infection rates increase dramatically. ♦ When infusing parenteral nutrition through CVCs . ♦ CVCs occluded for >24 hours increase the patient’s risk of infection exponentially! Treat blocked CVCs AS SOON AS POSSIBLE! Good hand hygiene before catheter insertion or maintenance combined with proper aseptic technique during catheter manipulation provides protection against infection. November 1981) INFECTION ♦ Infection is the most common complication of CVCs. The formation of fibrin begins within 24 hours of catheter insertion. 47 . • Partial and complete thrombotic occlusions are responsible for approximately 58% of all occlusions and develop as fibrin builds on and around the catheter and vessel. restricting blood flow and providing a place for bacterial growth. A normally functioning CVC should flush easily and there should be free-flowing blood return. embolism. fibrin tail.OCCLUSIONS • Central Venous Catheter (CVC) occlusion is the most common non-infectious complication related to CVCs. attempts can be made to unblock the catheter using the ® ® fibrinolytic agent Cathflo (alteplase ). or loss of vascular access. Thrombotic occlusions include fibrin sheath. continued assessment. and mural thrombis. FIBRIN SHEATH FIBRIN TAIL • If a catheter is partially or completely blocked as a result of thrombus formation. Thrombotic occlusions of a CVC can result in interruptions or delays in therapy. Blood components and cells adhere to fibrin. intra-luminal occlusion. infection. Proper care and maintenance. and early recognition of the pending signs of occlusions can improve patient outcomes and minimize organizational costs. lipid deposits. or complete inability to infuse or flush. PREVENTION OF OCCLUSIONS • Prevent occlusions by turbulent flushing before & after use. between incompatible medications. Lipid occlusions can be recognized by observing increasingly sluggish blood return in the lumen used to administer Parenteral Nutrition (always the Medial lumen on a triple-lumen CVC). or complete inability to infuse or flush call an RN who has been competency assessed to unblock the CVC (this may vary from site to site so check your local guideline) Treat occlusions promptly! Occlusions >24 hrs = INFECTION 48 . after blood draws. lack of free-flowing blood return. lack of free-flowing blood return. contact the Physician for further instruction. • If a catheter is partially or completely blocked as a result of drug precipitate or lipid deposits. Drug precipitation occlusions can be avoided by thoroughly flushing the CVC between incompatible medications. resistance to flushing. and mechanical obstructions. and regular flushes of lumens not in use • If there is resistance to flushing.• Non-thrombotic causes account for 42% of occlusions and include drug precipitates. but the inability to aspirate blood Rare . apprehension.g. Notify physician Swab insertion / exit site if it appears infected and send for C&S If ordered. cracks or leaks) • External: • Prepare for insertion of a new catheter by physician • Temporary or permanent repair is possible in some catheters including PICCs and tunneled CVCs. Call General Daycare or Home IV RN. lipids or precipitates within the catheter lumen or catheter malposition AIR EMBOLISM • Due to: − cut in line − catheter dislodgment − catheter separation (see Figure 1) − air in line • • Fever/chills Increased WBC Malaise Purulent drainage.COMPLICATIONS AND NURSING ACTIONS COMPLICATION SIGNS & SYMPTOMS INFECTION . blood clots. flush and reconnect system prn Internal: • Always check device for any signs of damage (e. especially between meds and blood draws Do not attempt to clear blockage by forceful flushing Thrombolytic therapy to unblock CVC by Competency Assessed RN with a Physician’s Order Remove the catheter on Physician’s Order if not salvagable Immediately clamp catheter proximal to patient Position patient on left side Trendelenberg Initiate resuscitative measures Obtain help & call physician “STAT” Immediately clamp catheter as close to patient’s skin as possible • Position flat • Aspirate air. Blood Cultures will need to be sent from each lumen (see pg 59) Send tip for culture if CVC removed Remove catheter only as last treatment of choice! Use only positive displacement caps for locking Routine flushing. etc. chest/shoulder pain • Change in level of consciousness • Dyspnea • Shock/vascular collapse • Cardiac arrest Asymptomatic/Potential for Air Embolism DEVICE MALFUNCTION NURSING ACTIONS Internal Causes: • “Pinch off syndrome”* • Rupture of the catheter from excess flushing pressure External Causes: • Improper clamping • Use of scissors or other sharp objects • Use of needles through the • • • • Aseptic technique with site care.may occur for a variety of reasons • • ƒ • • • • • • • • Symptomatic • Anxiety.Local or site infection . swelling.Incidence 3-10% (varies with device used) • • • • OCCLUSION Most common complication may occur as a result of fibrin sheath formation/ thrombus at the tip of catheter. erythema.ability to infuse fluids. 49 . restlessness. tubing changes. change IV set-up. tenderness at site Inability to infuse or withdraw from catheter Early sign .Systemic or intraluminal infection . notify physician If completely dislodged: .monitor for S&S of air embolism .decrease rate to TKVO .change solution to normal saline .position patient flat . then pressure dressing . e.position patient flat .apply pressure x 5 minutes. commonly the pericardial sac & pleural cavities Most common symptom is dyspnea • • • • Pain Erythema Occlusion Swelling Hot skin to touch • • • • • If partial dislodgment: .stop infusion . discomfort “stinging” during flushing • Discomfort may be localized to catheter exit site or at a distant location • Unable to get blood returns upon aspiration Catheter is dislodged completely/partially • Routine assessment & maintenance of site. if ordered Moist heat for PICCs only Antibiotic therapy Elevate extremity if PICC 50 .stabilize catheter . .continue to apply pressure for 5 minutes Assess patient post insertion Apply O2 Notify Physician ‘STAT’ if not at bedside Initiate cardio pulmonary resuscitation as necessary Eliminate irritating infusion Remove catheter.obtain help & call Physician “STAT” .notify physician ƒ Prepare for injection of Rogitine Do not remove IVAD needle • • • • CENTRAL VEIN PERFORATION Rare complication associated with left sided insertion • PHLEBITIS Due to chemical or mechanical irritant.notify MD Symptomatic: .COMPLICATION SIGNS & SYMPTOMS • • NURSING ACTIONS injection cap Constant moving and bending of elbow/shoulder in PICCs “Twiddler’s syndrome” (see pg 43) EXTRAVASATION • More common in IVADs when the needle becomes displaced CATHETER DISLODGMENT OR MIGRATION c/o pain.initiate resuscitative measures as necessary . If extravasation is suspected: .apply pressure to site Asymptomatic: .irritating IV fluids catheter movement Most often seen in PICCs • • • • • • Symptoms relate to site of perforation.g.position patient on left side Trendelenberg . COMPLICATION PNEUMOTHORAX Accumulation of air in the pleural cavity – often associated with insertion technique Increased incident during placement of a subclavian catheter VENOUS THROMBOSIS Rare 1-16% of CVCS May occur with short or long-term catheters SIGNS & SYMPTOMS • • • • • • • • • • • • • Dyspnea Cyanosis Chest pain Pain behind clavicle Hypotension Tachycardia Asymmetrical chest movement Decreased/absent breath sounds Arm or neck swelling External jugular distension Pain Numbness Weakness on affected side NURSING ACTIONS • • • • • • • Vital signs post insertion Chest x-ray post insertion Assess bilateral breath sounds Apply 02 to maintain SaO2 > 92% Elevate head of bed to 45° Call Physician “STAT” Prepare for possible chest tube insertion • • • • Observation Removal of catheter on physician’s order Long-term anticoagulation (3-6 months) Thrombolytic therapy Figure 1 Copyright © 2009 ECRI 51 . What is potentially the most deadly complication associated with CVCs? _______________________ 2. 52 . List 3 1) 2) 3) nursing actions for the treatment of air embolism __________________________________ __________________________________ __________________________________ 5. chills. Fever. 8. redness. ___________________ is one of the most common complications of CVCs. Signs & symptoms of air emboli are a sudden onset of __________ pain and sudden shortness of ___________. 6. List 5 ways of minimizing the chance of air entering the system? 1) ______________________ 2) ______________________ 3) ______________________ 4) ______________________ 5) ______________________ 3. 7. increased WBC. and purulent drainage are signs and symptoms of _______________. CVCs occluded for >24 hours puts the patient at increased risk for______________. tenderness at site. 4. Inability to flush or withdraw blood from a CVC is a sign of __________________.Test your Learning 1. What product must be used to prevent occlusions? _________________________ 9. infection. – the positioning of the patient on their left side in Trendelenberg position . Let’s keep moving….keep blue clamps/padded forceps with patient in case of catheter breakage .trendelenberg or flat positioning during insertions and removal of catheter 3. occlusion 8. air embolism. You’re almost there! 53 .. infection Congratulations! You have just completed the fifth section. chest.clamping the CVC (between the patient and air if possible) . infection 7. breath 4. – ensure the lumen is clamped prior to opening the system . positive displacement cap 9.have patient perform valsalva maneouver when risk of air embolism is high .Answers 1. or occlusion 6.use luer-lock connections .notify the physician 5. air embolism 2.cardiac and respiratory resuscitation measures . CARE AND MAINTENANCE OF CENTRAL VENOUS CATHETERS 54 . Therefore. pay particular attention to flushing and catheter care techniques MEDICATIONS AND TUBING ♦ Electronic infusion pumps must be used for all infusions administered through a CVC in the acute care setting (**Exception – Blood is not to be given through a pump at some sites.Care and Maintenance of Central Venous Catheters The two most frequent reasons for loss of central venous access are occlusion and infection. positive displacement caps may still be used. If the PICC needs to be repaired.The extension tubing that is added to a PICC line immediately after insertion is considered part of the PICC and is never changed. and after each use. when the CVC is being accessed frequently or dependant on the setting (i. however. blood q4h or 4 units) ƒ Intermittent infusion sets are changed a minimum of q 24 hours. ♦ Positive displacement caps – change q96h and prn 55 .e. the extension tubing is then considered to be an add-on-device and needs to be changed q96h along with the cap change. Community).) POSITIVE DISPLACEMENT CAPS ♦ Only positive displacement injection caps are used to cap CVCs ♦ Caps are not needed on lumens when there is a continuous infusion or CVP monitoring. o Community Care: ƒ Change tubing q 24 hours in clinic setting ƒ Change tubing q72 hours and prn in home setting ♦ All IV bags with factory added medications changed q96h ♦ All IV bags containing site added medications (including pharmacy added) changed q24h ♦ Luer-lock extension tubing on CVCs without clamps are changed with IV tubing and add-on devices q96h (**Exception . when contaminated. ♦ IV Tubing changes: o Acute & Residential Care: ƒ Primary Administration tubing changed q96h (TPN tubing q24h. Check your local Blood Administration guideline) ♦ All connections must be luer-locked. 44 • 56 .CLAMPS • • • • • • Clamps must be used when accessing and de-accessing an open-ended CVC to prevent air embolism or blood backflow. See OCCLUSIONS pg.DO NOT FORCE. Open-ended catheters are clamped at all times when not in use Clamps are not used on a valved CVC A padded forceps must be available at all times in the event of a break in the catheter lumen Do not use a sharp edged clamp or hemostat as they can damage the catheter Only clamp the reinforced segment of the catheter FLUSHING Always use 10ml syringes for flushes for CVC as excessive pressure (caused by syringes smaller than 10 mL when flushing and syringes greater than 10 mL when aspirating) can cause catheter damage • Flushing ensures patency of the catheter • All unused lumens must be flushed at specific intervals • Turbulent flush method (stop/start) should be used • At any time if unable to flush . assess for an occlusion (refer to Guideline). Flushes must be done with a 10mL syringe.9% 20 mL Sterile SODIUM CHLORIDE O.patency is assessed by the ability to aspirate for blood return AND the ability to flush a CVC without resistance prior to the administration of parenteral medications and solutions.e Portacath® or IVAD) Open ended Closed end Sterile SODIUM CHLORIDE O.FLUSH ROUTINES . followed by Sterile SODIUM CHLORIDE O. or after blood draw Patency Assessment All CVCs must be assessed for patency before each use .9% 20 mL Sterile SODIUM CHLORIDE O.Hickman®/Broviac®) Open Closed-end ended Long Term Implanted Port (i. If line is not patent.9% 20 mL Sterile SODIUM CHLORIDE O.9% 20 mL post-flush. DRESSINGS FAILURE TO ALLOW THE SKIN TO DRY COMPLETELY BEFORE APPLYING THE TRANSPARENT DRESSING MAY CAUSE A CHEMICAL BURN ON THE PATIENT’S SKIN DUE TO THE CHLORHEXIDINE IN THE CLEANSING SOLUTION.9% 20 mL Sterile SODIUM CHLORIDE O.Adult Long Term PICC Short Term CVC Type of Device Open Ended Open-Ended Closed-end Long Term Tunneled (i. 57 . capping.e. General Considerations .Always use aseptic technique and observe hand hygiene.9% 20 mL Sterile SODIUM CHLORIDE O. Use turbulent flush method (stop/start).9% 20 mL Once a month Solution for final flush (Lock solution) Sterile SODIUM CHLORIDE O.9% 20 mL followed by HEPARIN 10 units/mL (3 to 5 mL) Frequency of flush for unused lumens Q24H Q24H Q7 Days Q24H Q7 Days Once a month Flush capped CVC Sterile SODIUM CHLORIDE O.9% 10 mL pre-flush & between meds. If other bloodwork is needed. • In all cases. Post flushing: • Draw the blood. Use the largest lumen (usually distal) of multi-lumen CVCs whenever possible.BLOOD SAMPLING Key Points to Remember: • • • • • • • Peripheral sampling is the “Gold Standard” and should be done whenever possible and/or when the clinical situation does not preclude the use of peripheral sampling Blood must be drawn in a certain order. The only exception is when drawing coagulation studies. Never use the same lumen for TPN and blood draws. If a cap is necessary. Exception: Blood Cultures should always be drawn directly from the catheter hub. and attach the luer lock vacutainer directly to the catheter lumen. luer lock the vacutainer directly to the connector/ positive displacement cap and then change connector/ positive displacement cap following the blood draw. For drug levels. The use of the syringe method which utilizes a needle to fill the blood tubes is not a needle-safe method. Always draw blood cultures (when required) first. remove the administration set. For a capped CVC. Stop all infusions prior to blood sampling. consider the blood culture to be your discard amount. Have a dedicated lumen for blood draws if able. non-additive tubes should be used to collect the discard. the discard amount should be 10 mL. and then flush the CVC with 20 mL NS. Refer to the Fraser Health Lab Accessioning Manual for further information. This will prevent the development of occlusions from a thrombus or fibrin tail/sheath. • Do not discard before drawing blood cultures. When drawing blood from a CVC with a continuous infusion running without the use of a connector/ positive displacement cap. change the positive displacement cap (when one is present). • Use a needless or needle-safe system whenever possible. draw blood cultures through a new cap and change it again to another new cap when blood draw is completed. it is not recommended to draw the level from the same lumen being used for the drug infusion. 58 . Discard amount: • The discard amount when drawing blood is 5 mL. stop the infusion(s). ASSESSMENT MANAGEMENT OF PATIENTS WITH A CVC Pre-Insertion: • Vital Signs including BP. • NO blood pressures or venipunctures to be completed on arm where a PICC has been inserted • Check for signs of and report to Physician: • - Subcutaneous emphysema - Bleeding - Air embolus - Pneumothorax Ventilated patients: - • Ventilator system pressures changes Cardiac Monitored Patients: - Cardiac dysrhythmias 59 . HR and RR • Respiratory assessment including: breathing patterns. This is to prevent mechanical phlebitis. o o o o supine with no pillow for: Changing IV tubing or extension tubing Repositioning/removing catheter Initial capping/flushing Insertion • Any position for: o Blood work using vacutainer method o Flushing capped lines o Dressing changes Closed-ended catheters or IVADs do not require positioning to prevent air-entering catheter.PATIENT POSTIONING FOR CARE AND MAINTENANCE When caring for open-ended catheters patients should be positioned: • Flat. depth and symmetry of breath sounds Post-Insertion and q30 minutes x 2: • Vital signs (as above) • You may apply warm compress to arm above PICC insertion site – QID x 20 minutes for 3 days. The relatively long length and small diameter of an open-ended PICC significantly reduces but does not eliminate the risk of air embolus. If a line was placed under non-sterile technique.On admission. Central venous catheters should be removed when no longer necessary to decrease the risk of infection. 60 . and q4h check: • Dressing/site . • System check: - Catheter is secure. bleeding.) . • Assess the current coagulation values.) POINTS TO REMEMBER FOR THE REMOVAL PROCEDURE: • Place the patient supine in a slight Trendelenburg position. bruising. If the CVC is in the femoral vein. This causes a valsalva response. when the catheter’s presence could cause complications (e. dry and intact. the patient should be asked to exhale during the removal. (consult physician before removing if patient has elavated coagulation values. and presence of drainage. or when the patient has developed a catheter-related infection.g. cracks etc. or if a femoral CVC will be removed.secure. is on anti-coagulants. the line should be removed within 48 hours. tenderness. • Assess vital signs and neurovascular status of the extremity distal to the catheter insertion site. such as with glaucoma or retinopathy. swelling. If a valsalva response is contraindicated. warmth. redness. • Condition of site (any inflammation/infection. POINTS TO REMEMBER BEFORE REMOVAL: • Ensure presence of a physician’s order for removal. or has a pacemaker). no kinks. ask the patient to take a deep breath in and hold it.palpate around site. • If removing an internal jugular or subclavian catheter. at the beginning of every shift. Place the patient flat if Trendelenburg is contraindicated or not tolerated by the patient. drainage. - Condition of the catheter (i.e. subcutaneous emphysema etc.. such as during an emergency.) - All connections luer-locked and intact - Site condition and patency of infusion REMOVAL OF SHORT-TERM CVC AND PICCs Central venous catheters (CVCs) including peripherally inserted central catheters (PICCs) are removed when therapy is completed. The level of the catheter site should be below the heart to prevent air embolus during removal. extend the patient’s leg and ensure that the groin area is adequately exposed.e. the catheter is malpositioned). • Assess the catheter site for signs of infection (i. edema. If the patient is receiving positive-pressure ventilation. • Gently withdraw the catheter. steady motion. If resistance is met. • As the introducer exits the site. Because CVCs are placed in large veins.withdraw the catheter during the inspiratory phase of the respiratory cycle or while delivering a breath via a bag valve mask device. pulling parallel to the skin and using a constant. Use either a transparent. then 1 hour later as needed). • Upon removal of the catheter. • Apply a sterile dressing to the site. a gauze dressing is preferred. it may take up to 10 minutes for hemostasis to occur. The distal end of a multilumen catheter should be removed quickly because the exposed proximal and medial openings could permit the entry of air. apply pressure with petroleum-based ointment and sterile gauze (or a petroleum impregnated sterile gauze dressing). Notify practitioner immediately. direct pressure over the insertion site with petroleum-based ointment and sterile gauze (or a petroleum impregnated sterile gauze dressing). a segment of the catheter may be sent for culture. inspect the tip for integrity & length. Pressure may be needed for a longer period of time if the patient has been receiving anticoagulant therapy or if coagulation studies are abnormal. additional assessment. Place the catheter on a moisture-proof pad and dispose of properly. do not continue to remove the catheter.e. • Maintain bed rest for at least 30 minutes after catheter removal. • Continue applying firm. semi-permeable dressing or gauze dressing overtop of the petroleum impregnated sterile gauze dressing. Assess the site for signs of bleeding every 15 minutes times 2. every 30 minutes times 2. If damage to or fragmentation of the catheter is observed. and prn (i. sealing the site until bleeding has stopped. If the patient is diaphoretic or if the site is bleeding or oozing. is warranted. If an infusion-related infection is suspected. such as a chest radiograph. 61 . • Change dressing and assess site every 24 hours after catheter removal until site is epithelialized. one set drawn percutaneously from a peripheral vein and one set drawn through the CVC. cap change). • Hand hygiene . clean dressing cart or bedside table using bactericidal wipes. UB D O Y OU S W ICH H CRUB? WH HUB DO YOU SCRUB? HICH • Friction scrub the Positive Displacement IV Cap when accessing through the cap • Friction scrub the CVC hub when removing/changing cap • Always scrub using an alcohol swab for 30 seconds allow to dry completely 62 . • Positive displacement IV caps are changed q96 hours. • CVC dressings are changed q7days and prn. • Mask and wear sterile gloves for all times that the line is opened (eg. or when contamination is suspected. One set is drawn with two aerobic bottles. Additionally with a suspect CLA-BSI. samples need to be collected from at least 2 sites. Routine Practices (including hand hygiene.cleanse hands using hospital approved alcohol hand gel as per Infection Control protocol. the other set with one aerobic and one anaerobic bottle. if the source of sepsis is unknown. the site is uncovered. • Prior to all procedures. and blood and body fluid spills clean-up. application of personal protective equipment. • Routine culture of CVC catheter tips is not recommended. once the CVC is removed send the suspect catheter tip (distal 4-5 cm) to the lab in a sterile C&S container for semi-quantitative culture (see FH Laboratories Microbiology Manual). and sharps handling and disposal) and Additional Precautions. and with all immunocompromised patients. it is recommended that one aerobic Blood Culture set (two green aerobic bottles) be drawn from each lumen of the suspect CVC AND one Blood Culture set (two green aerobic bottles) be drawn from a peripheral site HOWEVER. • Blood Cultures: o o o For the diagnosis of a Central Line Associated Bloodstream Infection (CLABSI).INFECTION CONTROL • All staff will follow the latest Infection Control Guidelines for Principles of Infection Prevention and control. after blood draws. • All positive displacement IV caps and injection ports must be cleansed with a 70% Alcohol swab for 30 seconds and let dry completely prior to accessing. if unable to flush – Stop. remove the cap and try to aspirate from a syringe connection directly with the catheter hub • If line flushes easily.TROUBLESHOOTING A BLOCKED CATHETER If no blood returns: • Reposition patient • Ask patient to lift arms. • Insert new syringe with NS and flush. proceed with flush • If a positive displacement cap is present. on admission. • Competency Assessed RNs on specified care units may administer two doses of fibrinolytic with a Physician’s Order If still no blood return or inability to flush ~ label line as “BLOCKED/ DO NOT USE” and notify Physician immediately. If you have free-flowing blood return. CVP should be continuously monitored and documented routinely. • Remove syringe • Clamp line MONITORING CENTRAL VENOUS PRESSURE (CVP) When clinically indicated in a Critical Care area. If air is present (remember to scrub the cap/CVC hub with an alcohol swab for 30 seconds and allowing to dry before accessing): • Withdraw air from catheter using a syringe • Remove the syringe from the positive displacement IV cap • Expel the air from the syringe. continue with the procedure If you still have no blood return or difficulty/inability to flush: • Gently attempt to flush with NS • Do not force . label line as “BLOCKED/ DO NOT USE” and notify Physician requesting orders for fibrinolytic. cough and perform Valsalva manoeuvre • Ask patient if usually able to aspirate blood from the line • Re-aspirate for blood. the beginning of every shift and a minimum of q4h and: following a bolus IV fluid or a blood product transfusion following the initiation of vasopressor or vasodilator therapy after significant vital sign change As per Physician’s Order 63 . 64 . notify Physician.REPORTABLE CONDITIONS Report the following conditions to the Physician: • Inappropriate fluid administration • Non-functional/dislodged catheter • Changes in patient assessment (vital signs) • Changes in CVC assessment that may indicate: o Bleeding o Mechanical or infectious phlebitis o Cellulitis o Localized infection or Sepsis o Partial or complete occlusion o Loss of patency – partial or complete occlusion • Check catheter length. If length of visible portion (external to insertion site) is greater than 4 cm from the length stated on the insertion record. How often should an un-accessed IVAD be flushed? Q__________ 12. T F ____________ 4. A clampable portion of tubing is not necessary for open-ended catheters. ___ tubes(s) of blood must be discarded. and q12hours. Two small smooth-edged clamps are to be at the bedside. percutaneous CVCs should be flushed immediately after capping. ____________________ 4 situations when a capped CVC should be flushed. blood work. When should an electronic infusion device be used? 10. T F 9. ______________________________ ______________________________ ______________________________ ______________________________ 65 . IV medications. Capped short-term. State a) b) c) d) 11. Blue dead-ended caps are acceptable to cap a CVC in the FHA. When performing a blood draw from a CVC. please write correct answer): 1. 3. IV tubing is changed q96hours (except blood. T F ____________ T F ____________ T F ____________ 6. Patient must be in Trendelenberg for routine dressing changes. TPN). 5 Percutaneous CVC site dressings are changed q10days and prn. T F ____________ 7.Test your Learning True or False (If False. Positive displacement caps are changed q72hours. T F ____________ 8. T F ____________ 2. 2.Answers: 1.only positive displacement caps are used to cap CVCs in FHA . 8. 4. False .all open-ended CVCs must have a clampable portion An electronic infusion device must be used for all IV infusions administered through a CVC (**Exception – Blood is not infused with a pump at some sites).patients transferred from other facilities may not have them False . 10. 12. 5. 7. 11. 3.one smooth edge clamp is required at bedside False – caps are changed q96h False False False .patient may be in any position for a dressing change True False . 9. a) q24h b) following CVC capping c) following IV medications d) following blood work monthly or q28days 0 – when drawing blood cultures 1 – when patient has bloodwork with NO coagulation studies 2 – when the patient has bloodwork with coagulation studies ordered You have just completed a self-learning module that has outlined the basic principles of central venous catheters! 66 . 6. Health Devices. Restoring patency to central venous access devices. Corrigan. Bishop. L. Ottawa:ON: Author. St. Laboratory Medicine and Pathology Sample Collection and Dispatch Instructions. Bard Access Systems Inc. R. Hospital Pharmacy.transfusionmedicine. A.. 2011.. 29 (261-278). 81-84. Fraser Health Authority (2010) Scope of Practice. Beasley. Pg. Laboratory Medicine and Pathology Sample Collection and Dispatch Instructions. Cohen.). Author.. C.. Retrieved from http://www. Philadelphia: W. Louis. In Craig J. 67 . 925-934. MIC 0250.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.6-10. M. Vancouver. Edwards Lifesciences (2002) Quick Guide to Central Venous Access. C. et al (2007) Guidelines on the insertion and management of central venous access devices in adults. Alteplase (Cath-Flo®). L. M. Author: Salt Lake City. T. 37(9). The evidence-based practice manual for nurses (second ed. (Eds. Parenteral Drug Therapy Manual (Adult). & Perucca. 26(6). Hankins. No. Journal of Infusion Nursing. (2007) Nursing Procedure Manual. Alexander. Author. 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Plumer's Principles & Practice of Intravenous Therapy (8th ed. APPENDICES APPENDIX A: Responsibility for CVC Management APPENDIX B: Central Venous Catheter Insertion and Removal Form APPENDIX C: Regional CVC Maintenance Worksheet APPENDIX D: CVC Skills Inventory 70 . PICC Removal of air Blood specimens Who is Responsible Competency Assessed RN Competency Assessed RN Competency Assessed RN Competency Assessed RN Insertion of PICC Physician or Advanced Competency Assessed RN Advanced Competency Assessed RN Advanced Competency Assessed RN Competency Assessed RN on specified care units Repair of Tunnelled Catheter Repair of PICC Catheter Instillation of fibrinolytic Competency Physician Competency Competency Competency Assessed RN Assessed RN Assessed RN Assessed RN Competency Assessed RNs shall perform the following Central Venous Catheter (CVC) Competencies: • • • • • • • • • • • • • • Assist Physician during insertion and manipulation of CVC Obtain blood specimens from a CVC Access a CVC Dress a CVC site Change IV tubing Convert a continuous CVC infusion to a capped system Convert a capped CVC to a continuous infusion system Change a positive displacement cap on a CVC Flush a capped CVC Check patency and remove air from a CVC Manage partial and complete CVC occlusion by administering a fibrinolytic Removal of a non-tunnelled.Percutaneous (short term) .Tunnelled CVC and IVAD . non-implanted percutaneous central venous catheter (Short-term & PICCs) Obtain central venous pressure (CVP) measurements (Critical Care Areas only) Insert short obturator cap into Percutaneous Introducer Sheath with sideport to ensure closure of hemostasis valve (in Critical Care Areas only) Advanced Competency Assessment is required for the following CVC skills: • • Insertion and repair of PICC lines Advanced Competency Assessed Renal RN may cap and flush hemodialysis catheters 71 .APPENDIX A: RESPONSIBILITY FOR CVC MANAGEMENT Procedure Access & de-access CVCs Dressing Change all CVCs IV Tubing Change: all CVCs Cap/Uncapped/Flush: all CVCs Removal of CVC . APPENDIX B: Central Venous Catheter Insertion and Removal Form 72 . APPENDIX C: Regional CVC Maintenance Worksheet 73 . APPENDIX E: Central Venous Catheter (CVC) Skills Inventory NAME: __________________________________ UNIT: _____________________ CNE/MENTOR: ____________________________ 1) Specialized Skill: Capping a CVC/ Changing a positive displacement cap Date of Theory & Lab CNE Signature Clinical Performance CNE/Mentor Evaluation date Signature 2) Specialized Skill: Flushing a capped CVC Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 3) Specialized Skill: CVC Dressing Change Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 4) Specialized Skill: Changing CVC solution tubing Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 5) Specialized Skill: Blood sampling from a CVC (vacutainer and/or syringe method) Date of Theory & Lab CNE Signature Clinical Performance CNE/Mentor Evaluation date Signature 6) Specialized Skill: Accessing an Implanted Port Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 7) Specialized Skill: De-accessing an Implanted Port Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 8) Specialized Skill: Removing a Short-term CVC or PICC Date of Theory & Lab CNE Signature Clinical Performance Evaluation date CNE/Mentor Signature 74 . 75 . 76 . Fraser Health Authority Vascular Access Regional Shared Work Team ©2011 77 .