Central venous catheters


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Central venous catheters

  1. 1. Central Venous CathetersDuring hospitalization, central venous catheter (CVC) care isoverseen by RNs to ensure safe and effective intravenous therapy Following receipt of physician’s order for placement, arrangements are made as needed by nursing If placing a central venous catheter at the bedside; • Obtain central line cart from OPCC if line is placed on any of the general nursing units • Obtain CVC Tray & Central Line Insertion Drape Kit • Have permit signed • Assist at the bedside as needed • Monitor for quality during placement procedure • Complete CVC Insertion Checklist and place in managers box
  2. 2. CVC (continued)CVC insertion is a sterile procedure for which a “Bundle” has been recommended to reduce blood stream infections Optimal Hand Hygiene using chlorhexidine is performed Optimal Site Selection is performed by the physician • (Subclavian as opposed to femoral) Optimal Site Preparation is performed - chlorhexidine prep – 30 second scrub with 30 second dry time or 2 minute scrub with 1 minute dry time for wet areas Optimal Barrier Precautions are performed : For the physician inserting the line and those assisting with the procedure, required proper protective equipment includes: cap, mask with eye shield, sterile gown and gloves
  3. 3. CVC (continued) All others in the room must have cap and mask - including patient The patient should be draped completely from head to toe with the exception of a small opening at the site of insertion All participants, (physicians and nursing) are responsible for maintaining all components of optimal line placement. The physician is responsible for site selection, maintenance of sterile field, confirmation of patency, daily observation of line and prompt removal of catheter The assisting nurse is responsible for holding the physician accountable for asepsis during placement
  4. 4. CVC (continued) Once the CVC has been placed, nursing awaits a confirming radiology report prior to using the CVC unless otherwise ordered by the physician An order must be obtained from the physician (not the radiologist) prior to using the CVC Intravenous infusions via CVC are initiated by the RN LPN’s may replace primary bags without medication additives and hang piggyback antibiotics - All IV push meds, including flushes, are performed by the RN All unused ports of CVC’s are flushed every 12 hours and as needed following medication administration with at least 10 ml of normal saline (NS)
  5. 5. CVC (continued)Blood may be drawn from central venous lines for lab work per physician orders as follows: • Withdraw and waste 5 ml • Withdraw sample (volume determined by lab) • Flush with at least 10 ml NS • Flush with 20 ml NS if a PICC
  6. 6. CVC (continued)CVC dressings are changed by RNs weekly or sooner ifcompromised, under aseptic technique. Dressing changes are performed by RN’s with regard for: • Excellent hand hygiene • Proper use of barrier equipment • Thorough cleansing and inspection of the insertion site • Use of the Chloraprep • Use of the Biopatch • Tubing and caps are changed every 96 hours coinciding with fluid changes every 24 hours and dressing changes every 7 days • Date and time all CVC dressing and tubings • Education reinforcement for patient and family • Proper documentation
  7. 7. CVC (continued)Removal of CVC Upon receipt of order to discontinue CVC, the RN educates the patient regarding removal While the patient’s face is turned away from the CVC and aseptic technique is in use, the patient is asked to briefly hold their breath while the CVC is removed Firm pressure is held to the site for at least 5 minutes An occlusive, pressure dressing is applied and the patient is instructed to leave in place 24 hours During the pressure holding phase, the patient is encouraged to avoid talking, laughing, or coughing as these activities may lead to risk of an air embolism
  8. 8. CVC – Peripherally Inserted Central Venous Catheter PICC is a Peripherally Inserted Central Venous Catheter that is inserted into the peripheral vein and advanced until the catheter tip rests in the superior vena cava next to the right atrium A PICC is similar to a traditionally placed CVC except the complications are fewer and the dwell time is longer A PICC may have a single or multiple lumens. It may also have a “purple port” which is a power port meaning it can be power injected with contrast media by Radiology. Only a power PICC can be power injected
  9. 9. CVC – Peripherally Inserted Central Venous CatheterA PICC is not appropriate for all patients and proper selection todetermine the appropriateness of a PICC is necessary. The followingare some indications for a PICC:  Extended IV therapy for antibiotics, chemotherapy, or other medications  Parenteral nutrition with dextrose > 10%  Continuous infusion of vesicant medications or medications with ability to cause necrosis if infiltrated  Lack of vascular access  Patients requiring IV therapy after discharge  IV fluids with a PH less than 5 or greater that 9, or osmolarity greater than 600
  10. 10. CVC – Peripherally Inserted Central Venous CatheterProcedure - Once a PICC is ordered by the physician, the PICC nurse isnotified of patient need by calling the operator and having her paged.  A consent form is signed for PICC placement  PICC standing orders are placed on the chart and added to the Med- Act  A CVC checklist is filled out as with all CVC (PICC nurse should fill out the CVC checklist)  The PICC nurse fills out a Patient Assessment Form and this is placed in the chart  A sign is placed at the head of the bed labeled “PICC LINE IN PLACE” the PICC nurse may place the measurements hereOnce the PICC is placed, a CXR is completed for placement  Line confirmation is communicated to the primary physician who gives IV orders  If repositioning of the catheter is needed, the PICC nurse is notified
  11. 11. CVC – Peripherally Inserted Central Venous CatheterMaintenance: Sterile dressing changes using the Biopatch and Statlock device are completed every seven days unless the dressing is loose or soiled and needs changing sooner IV tubing and caps are changed every 96 hours Prior to accessing the cap of the PICC “scrub the hub” for 15 – 30 seconds with an alcohol pad to decrease risk of infection Upper arm circumference at the PICC insertion site is measured and compared with the initial insertion measurement and documented daily in CPSI Any retraction of the catheter is also assessed and compared with the length documented at the time of insertion and documented daily in CPSI
  12. 12. CVC – Peripherally Inserted Central Venous Catheter These measurements are compared to the measurements documented on the Patient Assessment Form by the PICC nurse on insertion The PICC nurse is notified of any changes in these measurements The appropriate sign is placed at the head of the bed to alert associates of “no needle sticks, tourniquets, or blood pressures to affected arm” If the patient has a temp over 101 degrees F at anytime the physician is notified
  13. 13. CVC – Peripherally Inserted Central Venous Catheter The PICC is used for lab draws as ordered on the standing orders The pull/pause technique is used when aspirating blood Always waste at least 10 ml prior to the blood sample If patient has TPN infusing, lab needs to be drawn from a different port not the port in which the TPN is infusing All drug levels are drawn from a different port as well, not the one the antibiotic or other medication was infused in The red lumen needs to be saved/marked for blood draws The PICC is always flushed with 20 ml of normal saline after blood draws or blood transfusions using the push/pause technique
  14. 14. CVC – Peripherally Inserted Central Venous Catheter Routine flushes are 10 ml normal saline per shift as with all CVC using a 10-12 ml syringe If a patient is admitted to WCMC with a PICC the PICC nurse is notified The PICC nurse is also notified with any issues related to the PICC such as an occluded line or breakage. The physician is notified and then the PICC nurse
  15. 15. CVC – Peripherally Inserted Central Venous Catheter An RN may remove a PICC IF he/she has credentials or a competency check sheet signed by a PICC nurse and this is in their inservice file All paperwork (listed below) related to PICC are located on the intranet attached to the policy in the nursing manual • CVC Checklist • PICC consent • PICC standing orders • PICC Patient Assessment • PICC sign • PICC removal check off form
  16. 16. CVC – InfusaportsAccessing Infusaport Upon physician order, infusaports are accessed utilizing aseptic technique using only non-coring access device (Huber needle) During the access process, patency is confirmed by positive blood return during aspiration and flush Blood is not routinely drawn from standard infusaports for lab work unless an order from the physician is received Following accessing the site, a sterile dressing is applied Unlike temporary CVC’s or PICC’s, infusaports require heparinization to maintain patency
  17. 17. CVC – Infusaports (continued)Routine Infusaport Use Ports that are accessed, but not in regular use, (i.e. lock), are flushed once daily with 10 ml NS followed by 10ml Heparin flush (10 units/ml) for a total of 100 units Following use of the infusaport for continuous IV administration, the infusaport is flushed with 10 ml NS followed by 10 ml Heparin (10 units/ml) flush The infusaport is flushed with 10 ml NS between IV meds If at any time the site becomes edematous, painful, or will not flush, infusions are stopped immediately and the physician is notified
  18. 18. CVC – Infusaports (continued) Sterile dressing changes are performed by the RN weekly and at any time that the dressing is compromised All infusaports are re-accessed weekly with dressing change, tubing change, and fluid change - date and time all dressings and tubings All fluid bags are changed every 24 hours All tubing and caps are changed every 72-96 hours in conjunction with tubing change and with re-accessing the port on day 7 LPN’s may replace primary fluid bags (without medication additives), and hang piggyback antibiotics All IV push meds (including flushes) administered via infusaport are given by RN’s
  19. 19. CVC – Infusaports (continued) De-accessing Infusaport Prior to de-accessing, the Infusaport is flushed vigorously with 10 ml NS followed by 10 ml Heparin flush Once the non-coring needle device is removed, observe the site for adverse signs No dressing is required following removal Instruct the patient regarding follow-up as ordered by physician
  20. 20. CVC – Infusaports (continued) De-access with two fingers on base: To de-access the port, approach the safety needle from behind - Place fingers on the base to stabilize it With the other hand, place a finger on the tip of the safety arm Lift the safety arm straight back Notice that the needle comes out perfectly straight “Click” needle into lock position: Continue lifting until the needle “clicks” into the lock position The safety needle is now ready for disposal into a sharps container
  21. 21. CVC – Power Ports Power Ports differ from standard infusaports in both shape and function The hub of a power port is triangular in shape Power Ports have three palpation points on the septum arranged in a triangle The patient may also provide a card or keychain identifying their port as a Power Port Power Ports are identifiable by x-ray Recently placed Power ports at WCMC will have a placement sticker located in the chart
  22. 22. CVC – Power Ports Power Ports must be positively identified by two means before being used for power injection In contrast to standard ports, Power Ports can be used to power inject contrast dyes needed for radiology exams Power Ports may be accessed with standard Huber needle devices, but a PowerLoc Safety Infusion Set is required if the port is to be used for power injection of contrast dye PowerLoc Safety Infusion Sets are kept in Radiology Blood may be drawn from Power ports with physician order All other routine care is the same for both types of ports
  23. 23. CVC – Use of HD cath for IVCatheters used for hemodialysis should be reserved for HD useonly unless extenuating circumstances exist Following failed peripheral IV insertion per the protocol for difficult IV starts, the attending physician may give orders to utilize the HD catheter for intravenous therapy An order set Utilization of Hemodialysis Catheters for Intermittent Intravenous Infusion standardizing the access procedure is found in the CVC policy in the Nursing Manual #6000.0208 Nephrology must be contacted prior to accessing the device
  24. 24. CVC- Use of HD cath for IVKey points related to this procedure are as follows: Ensure sterility Use only the blue “venous” port Use only Betadine - no alcohol based products including chlorhexidine are used Aspirate previously instilled heparin prior to use After successful aspiration, flush with 10 ml NS RN’s assume responsibility for all aspects of care Upon completion, flush with saline and re-heparinize with 2.5 ml of heparin, noting that the concentration is 1000 units/ml. Dressing changes to be completed during dialysis