Central venous line

2. Outlines
 Definition of cvc
 Indication
 Complication
 Definition of cvp
 Factors that increase CVP
 Factors that decrease CVP
 Procedure of cvp measuring
 Nursing care for cvp (dressing change)

3. Definition
Central venous catheter ("central line", "CVC",
"central venous line" or "central venous access catheter")
is a catheter placed into a large vein in
the neck (internal jugular vein ), chest (subclavian
vein or axillary vein) or groin (femoral vein). It is used to
administer medication or fluids, obtain blood tests
(specifically the "mixed venous oxygen saturation"),
and directly obtain cardiovascular measurements such
as the central venous pressure.

4. Peripheral inserted central
catheters
 the basilic and brachial veins are utilized for
peripherally inserted central catheters (PICCs).

7. Central venous catheter

8. Central venous catheter

9. CVC during insertion

10. CVC during insertion

11. Indication
 Monitoring of the central venous pressure (CVP) in
acutely ill patients to quantify fluid balance
 Long-term Intravenous antibiotics
 Long-term Parenteral nutrition especially in
chronically ill patients
 Long-term pain medications
 Chemotherapy

12. Indication

13. Cont.
 Drugs that are prone to cause phlebitis in peripheral
veins (caustic), such as:
 Calcium chloride
 Chemotherapy
 Potassium chloride
 Vasopressors (e.g. epinephrine, dopamine)

14. Cont.
 Dialysis
 Frequent blood draws
 Frequent or persistent requirement for intravenous
access
 Need for intravenous therapy when peripheral venous
access is impossible
 Blood
 Medication
 Rehydration

15. Remember
 Central venous catheters usually remain in place for a
longer period of time than other venous access devices,
especially when the reason for their use is
longstanding (such as total parenteral nutrition in a
chronically ill patient)
 Sterile technique is highly important here, as a line
may serve as place of entry for pathogenic organisms,
and the line itself may become infected with
organisms CLABSI

16. CLABSI
 Center Line Associated Blood Stream Infection
 Most hospital-acquired bloodstream infections are
associated with a central line (including peripherally-
inserted central catheters, PICCs), and CLABSIs are
responsible for excess mortality and morbidity,
prolonged hospital stays, and increased costs.

17. Insertion bundle
1. Maximal sterile barrier precautions(surgical mask, sterile gloves,
cap, sterile gown, and large sterile drape)
2. Skin cleaning with alcohol-based chlorhexidine(rather than
iodine)
3. Avoidance of the femoral vein for central venous access in adult
patients; use of subclavian rather than jugular veins
4. Devoted staff for central line insertion, and competency
training/assessment
5. Availability of insertion guidelines (including indications for central
line use) and use of checklists with trained observers
6. Use of ultrasound guidance for insertion of internal jugular lines

18. Maintenance bundle
1. Daily review of central line necessity
2. Prompt removal of unnecessary lines
3. Disinfection prior to manipulation of the line
4. Daily chlorhexidine washes
5. Disinfect catheter hubs, ports, connectors, etc before using the catheter
6. Change dressings and disinfect site with alcohol-based chlorhexidine
every 5 – 7 days (change earlier if soiled)
7. Replace administration sets within 4 days (immediately if used for blood
products or lipids)
8. Ensure appropriate nurse-to-patient ratio in ICU (1:2 or 1:1)

19. Complication
 localized infection
 Dysrhythmias:
may occur during the insertion process when the wire
comes in contact with the endocardium .
 Vessel laceration
 Right ventricular perforation
 Thrombophlebitis
 Hematoma at insertion site

20. Dysrhythmias

21. Cont.
 Pneumothorax
 Malposition of catheter
 Air embolism:
Rarely, small amounts of air are sucked into the vein as
a result of insertion technique. If these air bubbles
obstruct blood vessels , this is known as an air embolism

23. Measuring CVP

24. Measuring CVP
Definition:
describes the pressure of blood in the thoracic vena cava
, near the right atrium of the heart. CVP reflects the
amount of blood returning to the heart and the ability of
the heart to pump the blood into the arterial system.
Normal level :
 5 to 15 cm H2o at mid maxilla line

25. Factors that increase CVP include
 Hypervolemia
 Forced exhalation
 Tension pneumothorax
 Pleural effusion
 Heart failure
 Mechanical ventilation and the application of positive
end-expiratory pressure (PEEP)

26. Factors that decrease CVP include
 Deep inhalation
 Hypotension
 Hypovolemia

27. Procedure
 Perform hand hygiene.
 Place the patient in a supine position and explain the
procedure to patient.
 (If the patient can't tolerate being supine, make sure all
CVP readings are taken with the patient in the same
alternate position as ?)
 Locate the ZERO manometer at the intersection of the
mid-axillary line and fourth intercostal space.

28. CVP

30. CVP

31. Cont.
 If an I.V. solution is being infused through the CVP
monitoring line, temporarily stop it and flush the line
to prevent errors.
 Attach the hip saline (1ap heparin +500cm normal
saline ) to the the patient cathter stopcock.

32. Cont.
 Turn the stopcock so that the iv runs in to the patient
& open iv clamp.
 Then open from the patient to the ruler and take the
stable reading of the ruler.
 Resume the I.V. infusion if indicated

33. Nursing care
Change the dressing:
1. If possible, place the patient in a supine or semi-
Fowler’s position, with his/her head turned away from
the catheter site.
2. Don mask ,Wash hands.

34. Cont.
3 . Don non-sterile gloves and remove the dressing by lifting
the transparent dressing and stretching it away from the
catheter.
4 . Evaluate the insertion site. Observe for evidence of
infection, pain at the site of insertion of catheter, as well as
mechanical problems with the catheter (kinking, leaks,
improperly placed or missing sutures, etc.).
5 . Report problems to the patient's care provider and
document response, orders obtained/not obtained in Nurses
Notes.

35. Cont.
6. Remove non-sterile gloves.
7. Open the dressing change kit and don sterile gloves:
a. Scrub the catheter site and an area as large as the
dressing size around it, with an alcohol swab, from the
catheter entry to the periphery. Repeat two times. Allow
to dry.

36. CVC

37. Nursing care
 transparent polyurethane
film dressings such as
Tegaderm® and Opsite®,
 Transparent dressings must
be changed every seven days
or sooner if a. the
dressing is not intact (i.e.
there is no longer a seal)
 b. there is evidence of
inflammation
 c. there is excessive
accumulation of blood
and/or moisture under the
dressing

38. Cont.
b. Scrub the catheter site with antimicrobial or per unit
protocol, from catheter entry to the periphery , Allow to
dry.
c. Place the sterile dressing around the catheter insertion
site
d. Secure the catheter tubing and dressing with tape to
prevent the catheter tubing from being pulled or
disconnected.

39. Cont.
e . Note the date, time of the dressing change and your
initials on the outside of the dressing.
8. If the catheter dressing becomes soiled, wet, or loosened, it
must be changed according to the outlined procedure.
9. Remove gloves and wash hands.
8. Document dressing and tubing changes, and observations
of the catheter entry site in the Nurses Notes, and/or
Flowsheets.

40. Thank you