Central Venous Access Devices Made Incredibly Easy!

Central Venous Access Devices Made Incredibly Easy Adapted from a 2005 project

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

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

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

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?

1. Implanted Port vs. External Photo: C. Lewis Photo: Unknown

Implanted CVCs (Port-A-Cath) Insertion performed in O.R. or Radiology Suite

2. External: Tunneled vs. Non Tunneled Photo: Unknown

Peripherally Inserted Central Catheter (PICC) Photo: C. Lewis

3. Open-End or Groshong Valve Open-end Blood can back up in tubing Heparinized flush

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

5. Is the Catheter Designed for Dialysis or Apheresis? Photo: C. Lewis Photo: C. Lewis Patients receive ID card at time of insertion.

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

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

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

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

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

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

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

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

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

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

Fibrin Sheath Can extend along entire catheter tract and cause fluid to leak from insertion site

Fibrin Sheath Partial or total

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.

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

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

Fibrin Occlusion May be Amenable to Thrombolytic Therapy Intraluminal clot Fibrin sheath Fibrin tail Mural thrombus

Catheter Embolism Damaged or severed catheter Defective catheter Catheter rupture from forced injection Severed catheter from “pinch-off syndrome” Catheter damage during insertion

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

Management: Embolism Emergency situation! Notify M.D. X-ray to determine status Intervention by surgeon or Interventional Radiologist

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

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

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

Pinch-off Syndrome Source: Unknown

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

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

Accessed Port-A-Caths One the port is accessed, the non-coring needle can stay in for a period of time, depending on protocol.

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

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

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

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

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

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

Syringe Size and Flush Pressure Manufacturer recommendations 25 psi max.; 10 ml. syringes only Source: Unknown

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

Class Exercise Work in teams Five scenarios 6-8 minutes to do all Select a spokesperson

Percutaneously Inserted Central Catheter (PICC) 1

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

Implanted Vascular Access Device (Port-A-Cath) 2

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

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

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

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

Summary The key is to correctly identify the type of catheter Based on that, you can appropriately assess and maintain the catheter

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

Central Venous Access Devices Made Incredibly Easy!

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