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Central Venous Access Devices Made Incredibly Easy!
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Central Venous Access Devices Made Incredibly Easy!

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Target audience: RNs during New Hire Orientation and nurses needing additional training on identifying, assessing, and maintaining central lines. ...

Target audience: RNs during New Hire Orientation and nurses needing additional training on identifying, assessing, and maintaining central lines.

Developed in conjunction with subject matter experts (SMEs) from IV Team. Principles based on practice at this particular institution.

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  • Advanced
  • Super users group
  • If you can answer all of these questions, you can figure out how to assess and care for this catheter.
  • From http://www.aegis.com/pubs/step/1992/STEP4301.html Central Catheters, Implanted Ports Implanted ports have all of the advantages of a central line except they are not always immediately available for use. A port is a small titanium reservoir with a rubber "stopper" that is attached to the catheter entering your vein below the collarbone. The whole thing is implanted under the skin in an outpatient procedure with local anesthesia and IV sedation. These catheters are usually not noticeable under your skin, but may sometimes show as a small lump. In order to use this catheter, the nurse must locate and clean the site, and place a special needle through the skin and into the rubber stopper. This can be done for each dose of medication or left in place with a plastic dressing and weekly changes. Ports that remain in place between usages are usually bulkier and more cumbersome to "wear" than a tunnelled catheter, and the dressing needs to be kept clean and dry. The ports are made to withstand 2000 needle entries, but this does irritate the skin over the port. Most people develop a callus that quits hurting when the needle is placed through the skin. As a patient, you can be taught to clean the site and access the port with a needle, but it is difficult to learn and complicated to do. Because of the procedures involved in accessing the port for use, these catheters are usually not recommended for daily or more frequent medications. They are perfect for someone who gets a medication only once a week or for a week every six weeks or some other intermittent schedule. One type of implanted port is actually placed in the arm near the elbow and the catheter line threaded up the vein to the Superior Vena Cava, but they offer no particular advantage over a chest port, tend to have more complications, and are harder for the patient to self-access since two hands are almost required for the procedure. When the port is not accessed, it is hardly visible and requires no care other than a once monthly access for flushing with heparin. Patients with unaccessed ports can swim, though sometimes a doctor will recommend covering the site with a waterproof plastic dressing. Since the skin is an excellent barrier to bacteria, unaccessed ports rarely become infected. However, frequent accessing of a port, or leaving the access in place for extended periods can make the odds of infection greater than with with a tunnelled-type catheter. Blood can be drawn from a port for lab tests, if your doctor consents.
  • Super users
  • From: Nursing 92, June, p. 27 From Nursing 92, June, p. 27
  • Illustration adapted from Bagnall-Reeb, H. (1998). Journal of Infusion Nursing 21(5S):S115-S121.
  • Illustration adapted from Bagnall-Reeb, H. (1998). Journal of Infusion Nursing 21(5S):S115-S121.
  • Super users
  • If you can answer all of these questions, you can figure out how to assess and care for this catheter.

Central Venous Access Devices Made Incredibly Easy! Presentation Transcript

  • 1. Central Venous Access Devices Made Incredibly Easy Adapted from a 2005 project
  • 2. What You Will Learn Today
    • How to identify all types of CVCs
    • How to assess, monitor, and troubleshoot CVCs
    • How to initiate CVC care and maintenance according to Vascular Access Device Orders
    • How to flush CVCs appropriately
    • How to document CVC care and complications
  • 3. Unit RN Responsibilities: CVADs
    • Correctly identify type of CVAD
    • Monitor for complications & troubleshooting
    • Perform routine maintenance
      • Tubing, dressing, and cap changes
      • Flush lumens
    • Draw labs
    • Utilize specialty nurse and physician resources, as needed
  • 4. Types of Catheters
    • External Catheter
      • Tunneled
        • Open-end*
        • Valved
      • Non-tunneled
        • Open-end*
        • Valved
      • PICC
        • Open-end
        • Valved
    • Implanted Port
      • Chest (Port-A-Cath)
        • Open-end
        • Valved
      • Arm (PassPort)
        • Open-end
        • Valved
    *Catheter can be for dialysis
  • 5. To ID the CVAD, Assess the Following:
    • Implanted port or external catheter?
    • Is the external catheter tunneled or not?
    • Is the tip open-ended or valved (Groshong)?
    • How many ports/lumens?
    • Is the catheter designed and intended for dialysis or apheresis?
    • Where does the catheter enter the venous system?
    • Where does the tip terminate?
  • 6. 1. Implanted Port vs. External Photo: C. Lewis Photo: Unknown
  • 7. Implanted CVCs (Port-A-Cath) Insertion performed in O.R. or Radiology Suite
  • 8. 2. External: Tunneled vs. Non Tunneled Photo: Unknown
  • 9. Peripherally Inserted Central Catheter (PICC) Photo: C. Lewis
  • 10. 3. Open-End or Groshong Valve
    • Open-end
      • Blood can back up in tubing
      • Heparinized flush
  • 11. Groshong Valve
    • Valve is closed when there is no pressure
    • Positive pressure from syringe opens valve outward for fluid administration
    • Negative pressure opens valve inward for blood draw
    • Flush with NS - not heparin
  • 12. 4. How Many Lumens?
  • 13. 5. Is the Catheter Designed for Dialysis or Apheresis? Photo: C. Lewis Photo: C. Lewis Patients receive ID card at time of insertion.
  • 14. 6. Where Does the Catheter Enter the Venous System?
    • Central Entry
      • Is it tunneled or non tunneled?
        • Subclavian Vein
        • Internal Jugular Vein
        • External Jugular Vein
        • Femoral Vein
    • Peripheral Entry
        • Cephalic Vein
        • Basilic Vein
  • 15. 7. Where Does the Tip Terminate?
    • Superior Vena Cava
      • True central line placement
      • Best location is at right atrial junction
    • Inferior Vena Cava
      • If catheter is placed in femoral vein
    • Subclavian no longer desirable
      • High incidence of complications
  • 16. Assessing for Complications
    • Do bag-to-tip check
    • Examination of catheter tract is more involved for central line
      • Start with port site or skin entry site
      • Visually inspect along tunnel (if any) to venous entry site
      • Mentally think about where tip is and the complications that can arise
  • 17. Possible CVAD Complications
    • Infection
    • Ruptured/broken catheter
    • Occlusion
    • Thrombus
    • Phlebitis
    • Infiltration
    • Embolism
    • Interventions
        • Notify MD
        • Notify VAT
        • Alteplase therapy
        • Remove or repair the line
        • Refer to INS Policy & Procedure manual
  • 18. Infection
    • Prevented by sterile technique
    • Clues
      • Fever during infusion
      • Erythema, induration along tract; or
      • Drainage at insertion site
    • Need culture for diagnosis
      • Blood from catheter
      • Catheter itself
      • See INS Policy Manual for detailed instructions
  • 19. How to Draw Blood from Central Line for Culture
    • Sample should be “what is sitting in the line”
      • Draw 5-6 ml. From line and use that for the sample; DO NOT flush and discard first
    • If also drawing other labs, draw central line culture first
    • See INS Policy Manual for detailed instructions
  • 20. Damaged Catheter
    • Fluid leaking from catheter
    • Severed or ruptured catheter
    • Fluid leaking from hub or exit site
    • Cracked hub
    • Burning or pain with flush or infusion
    • Swelling along catheter tract
    • Some catheters can be repaired by specialty nurses
  • 21. Ways to Prevent Damage
    • Do not clamp catheter with hemostat
    • Do not force flush if resistance is met
    • Do not use needles
      • Connect syringe directly to hub or use needless connectors
    • Only use 10 ml. or larger syringes
    • Be aware that pinch-off sign can result in catheter damage
  • 22. Occlusion
    • Mechanical
      • External or internal
    • Non Thrombotic
      • Precipitate, lipid accumulation
    • Thrombotic
      • Intraluminal clot
      • Partial or total fibrin sheath
      • Mural thrombus
      • Fibrin tail
    Graphics showing different kinds of occlusions follow
  • 23. Lipid Accumulation
  • 24. Intraluminal Clot Formation
    • Clot inside the catheter
    • Caused by inappropriate flushing or heparinization
    • May be reversed with Alteplace or line may need to be removed or exchanged
    • Do not use force to attempt to open line
  • 25. Fibrin Sheath
    • Can extend along entire catheter tract and cause fluid to leak from insertion site
  • 26. Fibrin Sheath
    • Partial or total
  • 27. Mural Thrombus
    • Caused by irritation of the vessel wall by the catheter. Results in accumulation of fibrin and blood components. Catheter can eventually adhere to vessel wall. Thrombus eventually forms.
  • 28. Fibrin Tail
    • Can infuse but not aspirate
    • Infusate pushes fibrin out of the way
    • Aspiration pulls fibrin tail into catheter opening causes obstruction
    • Left untreated, it eventually becomes total occlusion
  • 29. Fibrin-Tail
    • For a period of time blood could not be aspirated from one port, but it infused well.
    • Eventually the lumen occluded. Alteplace could not open it.
    • This patient now has chemotherapy running into a peripheral line.
    Occluded Photo: C. Lewis
  • 30. Fibrin Occlusion May be Amenable to Thrombolytic Therapy
    • Intraluminal clot
    • Fibrin sheath
    • Fibrin tail
    • Mural thrombus
  • 31. Catheter Embolism
    • Damaged or severed catheter
      • Defective catheter
      • Catheter rupture from forced injection
      • Severed catheter from “pinch-off syndrome”
      • Catheter damage during insertion
  • 32. Clinical Findings: Embolism
    • Chest pain
    • Cyanosis
    • Hypotension
    • Tachycardia
    • Fainting or LOC
    • Arrhythmias
    • Cardiac arrest
    • Palpitations
    • Arm/shoulder movements may or may not interfere with infusion or blood withdrawl
    • Burning/pain with flush or infusion
  • 33. Management: Embolism
    • Emergency situation! Notify M.D.
    • X-ray to determine status
    • Intervention by surgeon or Interventional Radiologist
  • 34. Can Infuse But Not Aspirate
    • Something is not right -- do not ignore this
    • Look for pain or swelling, particularly while infusing
      • Catheter problem: pinched, kinked, or cracked
    • Could be ball-valve effect caused by fibrin tail
      • Alteplase therapy may help.
    • Consult specialty nurse
  • 35. Can Aspirate But Not Infuse
    • Reverse ball-valve effect
    • Caused by partial obstruction in catheter or implanted port reservoir
      • precipitate, fibrin, thrombus, or lipid
    • Call specialty nurse for evaluation
      • Possible need for thrombolytic therapy
      • Possible need for line exchange or replacement
  • 36. Pinch-off Syndrome
    • Can occur when catheter is “pinched” between clavicle and first rib
      • Catheter kinks, compresses
      • Line patency may vary with pt. position or movement
    • Hazardous, repeated catheter compression can shear the catheter
    • Always requires intervention
  • 37. Pinch-off Syndrome Source: Unknown
  • 38. Tunneled CVADs
    • Tunneling the catheter under the skin increases the distance from the port access to the venous access
      • Skin provides a germ barrier
      • Catheter has Dacron cuff that should never be visible
    • Assess entire length of tunnel track for signs of pain, reddness, induration
  • 39. Line Care
  • 40. Implanted Ports
    • Require special non coring needle and sterile technique to access
    • Access only by specially-trained nurses who have passed competency evaluation
    Photo: C. Lewis
  • 41. Accessed Port-A-Caths
    • One the port is accessed, the non-coring needle can stay in for a period of time, depending on protocol.
  • 42. Dialysis/Apheresis Catheters
    • Usually dedicated to therapy
    • Requires order by MD for use
    • MD must also order specific flushing protocol
      • Prescribed heparin dosage varies 1:1000 u/ml to 1:10,000 u/ml
    • If you must infuse into this catheter, never flush indwelling heparin into pt.
      • Withdraw 2-5 ml before infusing
  • 43. Managing Multiple Ports
    • Reserve the largest port for blood draws
      • Check manufacturer specifications for lumen sizes
      • Lumens often color-coded
      • Facility policy generally dictates usage practices
    • Smaller ports for TPN, heparin, other IV solutions/medications
    • Pause all infusions in all lumens before drawing blood
  • 44. Lab Draws from Central Lines
    • Stop all infusions (do not turn machine off)
      • Although the blood mixes quickly and carries solutions away, infusions from different ports can mix with blood drawn for lab work
      • Do not draw PTT from previously/currently heparinzed ports
    • Use sterile technique to separate a line from the catheter port
      • Cover the end of line with sterile needleless adapter or catheter
  • 45. Lab Draws from Central Lines
    • Use largest port
    • First, flush with NS 10cc
      • If TPN running through line, flush with more NS to eliminate all diluents that may cling to catheter wall
    • Withdraw and discard 5-6 ml blood
      • (can use flush syringe)
    • Use another syringe to draw sample
  • 46. After All Blood Draws or Blood Infusions
    • Clear the line of ALL blood – even if starting maintenance infusion
    • Flush with 20-40 ml. NS
      • PICC lines usually require NS 20-30 ml.
    • Restart fluid infusion, heparinze, or do positive pressure saline flush and clamp the line
    • If the catheter has a cap, draw the blood and flush through the cap
      • Change cap when blood accumulates and unable to clear with flushing, or every 24 hours – whichever occurs first
  • 47. Document All Flushes
    • On the MAR, use a system to identify particular ports and document flushes for specific ports
      • Red port, white port, etc
      • Proximal, middle, distal ports, etc
    • Institutional protocol dictates type of flush for specific devices
  • 48. Syringe Size and Flush Pressure
    • Manufacturer recommendations
      • 25 psi max.; 10 ml. syringes only
    Source: Unknown
  • 49. Flush Technique
    • To clear blood in central lines
      • Use intermittent positive pressure to create turbulence and thoroughly clear the line
        • 20-30 ml. NS
        • 2 ml – stop – 2 ml – stop – 2 ml – stop
    • After flushing any peripheral, open-ended, or Groshong cannula
        • Keep thumb on plunger and inject while withdrawing syringe
          • This prevents an air void that permits blood to back up into the cannula and form clots
  • 50. Class Exercise
    • Work in teams
    • Five scenarios
    • 6-8 minutes to do all
    • Select a spokesperson
  • 51. Percutaneously Inserted Central Catheter (PICC) 1
  • 52. Percutaneously Inserted Central Catheter (PICC)
    • Flush per facility protocol.
    • Inspect starting where the catheter exits the right basilic vein. Follow the catheter up the length of the arm. Look for signs of swelling, erythema, induration, pain, tenderness, and fluid leakage. Be alert for signs of tip migration forward (into right atrium) or backward (into subclavian vasculature).
    1
  • 53. Implanted Vascular Access Device (Port-A-Cath) 2
  • 54. Implanted Vascular Access Device (Port-A-Cath)
    • Flush per facility protocol.
    • Inspect starting where the port lies in the right chest. Follow the tract to the right internal jugular vein. Look for signs of swelling, erythema, induration, pain, tenderness, and fluid leakage. Be alert for signs of tip migration forward (into right atrium) or backward (into subclavian vasculature).
    2
  • 55. Subclavian Hickman Catheter 3
  • 56. Subclavian Hickman Catheter
    • Flush per facility protocol.
    • The venous entry and skin insertion site are very close to one another. Inspect around the skin entry site for signs of swelling, erythema, induration, pain, tenderness, and fluid leakage.
    3
  • 57. Tunneled Dialysis Catheter 4
  • 58. Tunneled Dialysis Catheter
    • Permission to use catheter, heparin concentration, flush amount, and frequency to be prescribed by MD. Heparin concentration usually 1,000u/ml. to 10,000u/ml.
    • Inspect starting at the skin exit site above the third rib. Follow the tract to the subclavian vein. Look for signs of swelling, erythema, induration, pain, tenderness, and fluid leakage. Be alert for signs of tip migration forward (into right atrium) or backward (into subclavian vasculature).
    4
  • 59. Tunneled Catheter 5
  • 60. Tunneled Catheter
    • 5 ml. NS flush to each lumen.
    • Inspect starting at the skin in the right chest wall. Follow the tract to the right external jugular vein. Look for signs of swelling, erythema, induration, pain, tenderness, and fluid leakage. Be alert for signs of tip migration forward (into right atrium) or backward (into subclavian vasculature).
    5
  • 61. Summary
    • The key is to correctly identify the type of catheter
    • Based on that, you can appropriately assess and maintain the catheter
  • 62. To ID the CVAD, Assess the Following:
    • Implanted port or external catheter?
    • Is the external catheter tunneled or not?
    • Is the tip open-ended or valved (Groshong)?
    • How many ports/lumens?
    • Is the catheter designed and intended for dialysis or apheresis?
    • Where does the catheter enter the venous system?
    • Where does the tip terminate?
    END