- Shared on the request of al the delegates who attended and those who couldn't attend the webinar on "CVC care- A Nursing Skill'' due to limited seats. I hope it will be helpful to all

1. CENTRAL VENOUS CATHETER CARE
A NURSING SKILL
Ms. Tsering Lamo
ICNO, AIIMS, New Delhi

2. • Introduction
• Definition - CVC
• Common sites of insertion
• Types of CVC
• Indications
• Technique of insertion
• Contraindications
• Complications
• CVC care
• CLABSI & CLABSI Bundle
• Key Points to Remember
• Patient Education
• Time to talk

3. Introduction
Central venous access is a standard procedure performed on
the hospitalized patient especially in the intensive unit.

4. Central Venous Catheter
• Central Venous line, Central venous access catheter,
Central line.
• Vascular access devices inserted into large vein in
the CVS.
• Made of polyurethane, silicon rubber or CVC.
• Commonly 15–30 cm in length.
• Radiopaque
• Used very frequently
in ICUs.

5. Which VEIN To choose ??
• Depends on :-
– Medical history &
vascular history related
any prior CVAD
placements.
– CVC type
– Activity level
– Preference
– Duration of treatment

6. Common Sites of Insertion
1. Centrally Inserted
• Rt Jugular Vein
• Lt Jugular Vein
• Rt Subclavian Vein CDC
• Lt Subclavian Vein
• Femoral Vein (as a last
resort)

7. Common Sites of Insertion
2. Peripherally Inserted
• Basilic Vein (1st choice)
– Larger (diameter- 3 to 6mm)
– Not in proximity of arteries or
nerves
• Brachial vein (2nd choice)
– Close to brachial artery &
medial nerve
• Cephalic Vein
– Only in selected pts like obese
– Too superficial
– Too many valves

8. Position of Catheter Tip
• Positioned inside the
Superior Vena Cava
• Catheter tip btw 55 & 29 mm
below the level of the carina.
Cavo-Atrial Junction

9. Types of Catheters
Short Term Use
• Single or multiple
lumen
• Pulmonary artery
catheter (Swan Ganz)
Long Term Use
• Tunneled
• Non –Tunneled
• Implanted
Port -A- Cath
• PICC

10. 1. Proximal Lumen -18G
-Blood sampling
-Medications
-Blood administration
2. Medial Lumen -18G
-Exclusively for TPN
3.Distal Lumen -16G
-CVP Monitoring
-Medications
-Blood administration

11. Tunneled Catheter
• Placed under the skin.
• Used for a longer duration
of time.
• The exit site is typically
located in the chest.
• Prevent infection and
provides stability.
• E.g., Hickman catheter

12. Non – Tunneled Catheter
• Fixed in place at the site
of insertion.
• Catheter & attachments
protrudes directly.
• Mainly used for HD
• E.g., Quinton catheters

13. PICC Line
• Much longer than CVC
(50–70 cm).
• Smaller in diameter than
central lines.
• Considerably slower
flow rate.
• Advantage : -
– Can remain in place for
several wks-month
– Low risk of infection &
complications,
– Ease of insertion,
– Low cost

14. Implanted Port
• Left entirely under the
skin.
• Surgically implanted
• Infusion ports are
placed below the
clavicle
(infraclavicular fossa).
• Medicines are injected
through the skin into the
catheter.

15. Implanted Port
• Some contain a small
reservoir (can be refilled)
• Reservoir slowly releases the
med into the bloodstream.
• Typically used on pts
requiring periodic venous
access over an extended
course of therapy.
• Easier to maintain & lower
risk of infection

16. Indications
1. Administer Meds (irritant drugs)
-Vasopressors, Chemo, Hypertonic sol.
2.Hemodynamic Monitoring
-CVP , Cardiac Parameters etc
3. Specialized Rx
-Plasmapheresis, HD

17. Indications
4. Parenteral feeding - TPN
5.Arrythmias (tip deep inside Rt atrium)
6. High Volume/ Flow Resuscitation
- Infusion of Fluid/ Blood Products
7. Poor Peripheral Venous Access

18. Technique of Insertion
Medical procedure to obtain safe access to blood
vessels & other hollow organs
1.
2.
3.
4.
5.

19. Contraindications
• Uncooperative pt
• Infection at the site of access
• Bleeding disorders
• Pneumothorax or hemothorax
• Distorted anatomic landmark from any reason

20. Complications
1. Pneumothorax
• In less than 1% of pts
• Require hospital stay to heal (2-4days)
2. Artery Puncture
• Accidental puncture of an artery (carotid)
• Hematoma- blood collects outside the artery
• Pts are observed for swelling
• Very rare (when USG guided)

21. Complications
3. CLABSI
• Serious infections
• Fatal in up to 25% of cases.
4. Occlusion
• Kinks in the catheter,
• Backwash of blood into the catheter leading to thrombosis,
• Infusion of insoluble materials that form precipitates.

22. Complications
5.Venous Air Embolism
• Rare but lethal.
• Fatal when at least 200–300 milliliters of air is introduced.
• Lead to heart failure, Pul edema.
6. Misplacement
• Mistakenly placed in an artery during insertion.
• When anatomy of the person is different or difficult due to
injury or past surgery.

23. CVC Care
• Meticulous care given to a patient with regard to
the CVC.
• To prevent-
– CLABSI
– Central line thrombosis, and
– Mechanical complications.
• Involves aseptic techniques.
• Typically performed by skilled Nsg or medical staff.

24. CVC CARE
1. STERILE DRESSING CHANGE
• Gauze dressings - every 2 days unless they are soiled,
dampened or loosened.
• Transparent dressings -every 7 days unless they are
soiled, dampened, or loosened.(CDC)
2. CAP CHANGE
• No more often than 72 hours (or acc. to manufacturer
recommendations)
• However, caps should be replaced when the
administration set is changed. (CDC)
3. FLUSHING
• Continuous
• Pulsative

25. Articles Required
1. A sterile tray containing : -
– Bowl with spirit swabs
– Artery forceps
– Thumb forceps
– Sterile gauze
– Sterile towel

26. Contd..
2. A clean tray containing; -
– Clean glove - 1 pair
– Sterile glove -1 pair
– Povidone iodine/2% Chlorhexidine sol./70% isopropyl
alcohol
– Kidney tray / Paper bag
– Transparent dressing/Tegaderm
– Normal saline/Heplock
– 10ml syringe , Triway
– Mask
– Label
– Sterillium

27. Procedure
1. Collect all articles at the bedside.
2. Explain the procedure to the patient.
3. Wash hands and put on the mask.
4. Don the clean gloves.
5. Remove the previous dressing using the spirit swabs.
6. Assess the site for signs of infection, oozing, swelling etc .
(if any, inform).
7. Remove the clean gloves & perform hand hygiene.
8. Open the sterile dressing set.

28. Procedure
9. Pour Chlorhexidine /Povidone Iodine/70% alcohol into the
sterile bowl.
10. Don the sterile gloves.
11. Clean the insertion site of the CVC with the Chlorhexidine/
Povidone Iodine/70% alcohol gauze in a circular fashion.
12. Clean the catheter lines with the Chlorhexidine /Povidone
Iodine/70% alcohol swabs.
13. Clean the site in concentric circles.
14. Let it dry on the skin.

29. Procedure
15.Apply the tegaderm over the CVC insertion sites,
securing the line and without any air trapped inside.
16.Scrub the injection hub with 70% alcohol (15 -30sec) &
let it dry(30sec).
17.Check the back flow and flush the line with
heplock/Saline.
18. Clean the caps of each line with 70% alcohol.
19. Wrap a sterile pad around the ports.

30. Procedure
20. Label with date and time.
21. Replace all the articles.
22. Perform hand hygiene.
23. Record in the nurses record : -
-Any redness, swelling or fever
-Break or leak in catheter
-Patency of all ports
-Loosening of fixation
-Length of indwelling catheter
-Date & time of dressing

31. CVC Care Video

33. • Syringe to be use :
Adult - 10 ml
Paeds – 1-5 ml
• Larger syringes:
less pressure when flushing and
more pressure when withdrawing or
aspirating
• Smaller syringes:
produce more pressure when flushing
less pressure when withdrawing

34. Flushing Technique

35. Flushing Technique
1. Continuous
• Continuous pushing of sol.
2. Pulsative
• Allows to “scrub or clean” the inside of the device wall.
• Promote removal of blood/fibrin
• Help prevent buildup of medication precipitate on the
internal lumen of the device

38. Pathogens Associated With CLABSI

39. Laboratory Confirmed Blood
Stream Infection (LCBI)

41. CLABSI BUNDLE - HaMCOD
Hand hygiene
Maximal barrier precautions upon
insertions/manipulation
Chlorhexidine /Povidine Iodine/Alcohol skin
antisepsis
Optimal catheter site selection with avoidance
of the femoral vein for CV access
Daily review of line necessity with prompt
removal of unnecessary lines

42. Last Mile……

44. 1. Maintain asepsis during –medication/blood sampling & during
infusion & flushing
2. Do not keep the cap over unsterile area.
3. Tip of med. Syringe should not touch unsterile area.
4. Flush after administration (SAS) of med. & after sampling
(SBS) or (SASH)
5. Injection ports should be closed & covered with a sterile gauze.
6. If port of a tri-way is smeared with blood, replace the same
with a sterile one.

45. 7. Change Gauze dressings - every 2 days unless they are
soiled, dampened or loosened.CDC
8. Transparent dressings -every 7 days unless they are
soiled, dampened, or loosened. CDC
9. Replace tubing that is used to administer blood, blood
products, or lipids within 24 hours of initiating infusion.
CDC
10. Change caps no more often than 72 hours (or according to
manufacturer recommendations); however, caps should be
replaced when the administration set is changed. CDC
11. Keep the IV set & the catheter as a closed system. Repeated
connections & disconnections should be avoided.

46. 12. Fluids & drugs should not be given through the TPN line.
13. Use pressure bags during rapid transfusion. Avoid pushing
through the 3 –way.
14. Once catheter is removed apply firm pressure. Take precautions
not to touch the tip of catheter.
 Tip of catheter should be sent for C/S .
 Puncture site should be covered with sterile dressing & tape.
 Dressing should be removed after 24hrs.
14. Details of removal are documented in the records (including
date, location, and signature and name of operator undertaking
removal.)

48. Conclusion