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PHOTO REFERENCE: http://community.nurseslounge.com/files/7750e5d445/1._CVAD.JPG
 Central Venous catheters or access devices can be
categorized into four groups based on their design:
o peripherally inserted central catheters
o temporary (non-tunneled) central venous catheters
o permanent (tunneled) central venous catheters
o implantable ports.
 Although tip location of all central lines may be the same,
insertion sites may vary.
 It is the responsibility of the Nurse to be knowledgeable
of the CVADs design, purpose, limitations, and
precautions and to educate patients and caregivers so
they can independently manage their catheters whether
in an inpatient, outpatient or homecare setting.
PHOTO REFERENCE: http://www.utmedicalcenter.org/lib/image/manager/pages/departments/radiology/radiology-patient-services/picc-team-
service/picchome1_opt.jpg
PHOTO REFERENCE: http://t1.gstatic.com/images?q=tbn:ANd9GcQmispXuKKSH9j2lAiEvPRIp35n8bg2u8WC0EEP9QDA0yNem5849s-vK2fY
 By definition, and per its’ acronym, A PICC line is a
peripherally inserted central catheter.
 It is a long (approx. 50cm or 20 inches) slender flexible tube
that is inserted into a peripheral vein, typically in the upper
arm of adults and children and sometimes the scalp and lower
extremity of pediatric patients.
 The PICC is then threaded along the vein into the subclavian
and eventually into the vena cava and central circulation.
 The Registered Nurse should understand that a PICC is a
central venous access device (CVAD) which requires the
same care as other central venous catheters to avoid
complications and achieve positive patient outcomes.
 In many Hospitals and outpatient settings the PICC line has
become the preferred alternative to central lines due to cost
effectiveness, ease of insertion and significant lower
incidence of major complications.
 Specially trained and certified nursing teams have been
effectively placing PICCs at the bedside, thereby decreasing
costs and enhancing patient comfort.
 Major complications such as hemothorax, pneumothorax, and
vessel rupture are not typically present with PICC insertion.
 In addition risk of infection is greatly reduced due to the mere
placement of the line: upper arm, verses neck or chest for
central line.
 PICC lines are commonly used in acute care settings,
homecare settings and skilled nursing facilities for a variety of
therapies.
 They are used for short term therapies of only 1 week to long
term therapies up to 1 year.
 Some of the various indications are:
o chemotherapy,
o parenteral nutrition
o repeated blood or blood products
o frequent venous sampling in those with poor venous access
o Central venous pressure monitoring in various critical care areas
Any infusate, regardless of osmolarity, pH, or other chemical
properties of a solution or medication can be administered via
PICC line.
o INS guidelines state that drugs which have a pH less than 5 and
 PICC lines are typically made of polyurethane and
silicone.
 They typically range in size from 4-7 French, but can be
as small as 1.1 French for neonates.
 Due to the increasing need for high-pressure injection for
CT Scans, the use of polyurethane PICCs (Power) are
increasing.
 Single, double and triple lumen PICCs are available.
 PICC lines are generally classified into either open ended or valved.
 An open ended catheter is generally maintained with a Heparin lock
solution because of blood reflux into the catheter tip.
 With a valved catheter, a valve is built into the internal tip or external
hub.
o The valve prevents blood from the vessel from inadvertently entering the
catheter.
 While these valves have different designs and function in different
ways, the one common aspect is the fact that they can be flushed
and locked with 0.9% Normal Saline solution only and do not require
heparin.
 Examples of these types of valved catheters are the
o Groshong Catheter
o Bard Solo PICC
o Vaxcel PASV
 PICC line placement can be done in both the inpatient
and outpatient setting and is performed by trained and
qualified health care professionals such as :
o Radiologists
o Physician assistants and certified
o Certified Registered Nurses.
 The Basilic vein is preferred because of its large
diameter; however the Cephalic vein can be used.
 Least preferred are the Brachial veins due to increased
risk of complications.
 There are 2 techniques commonly used to insert a PICC
line.
o The Peel Away Cannula Technique is performed by feel only and
then advanced and confirmed under fluoroscopy.
o The second technique known as the Modified Seldinger
Technique involves ultrasound guidance to visualize the vessels
in the upper arm then placement confirmation via fluoroscopy or
chest x-ray.
 Latest technology now combines ultrasound for vein
access, magnetic tip location, and electrocardiographic
(EKG) guided positioning for final tip confirmation.
o This method prevents patient’s exposure to radiation and saves
time in repositioning catheter in the case of previous malposition.
 Arm circumference at the insertion site should be
measured at time of insertion and recorded for future use
to identify swelling that may not be accompanied by
erythema.
 Catheter measurements should also be documented in
the patient record.
o They should include total length, and external length.
 Insertion measurements are necessary for PICC removal
and ongoing assessment.
 Accessed arm should not be used for phlebotomy or
Blood pressure measurement.
 National Standards of practice, FDA, and CVAD
manufacturers recommend placement of the PICC tip
terminating in the distal end of the superior vena cava (SVC)
at or near its junction with the right atrium.
 The Infusion Nursing Standards of Practice recommends that
all members of the Health care team collaboratively address
CVAD tip location if the SVC is not used.
 Nerve injury or irritation can be a complication during insertion
of a PICC line, nearby nerves may get injured or irritated.
 Signs and symptoms include:
o shooting pains down the arm
o numbness and tingling
o sensation of pins and needles
o weakness or in extreme cases paralysis. Though an uncommon
complication it is occurs most when the brachial vein is selected.
 INS guidelines no longer list dressings as stabilization
devices.
 CVADS should be secured to minimize movement in and
out of the insertion site.
 A manufactured catheter securement device is now the
preferred alternative to tape or sutures when feasible.
 These devices help reduce catheter dislodgement and
the need for removal and reinsertion.
 The chosen device should allow for assessment of
catheter insertion site and should not alter the flow of
fluid through the catheter.
 The securement device should be changed with the weekly
dressing change or when loose or soiled.
 Migration and dislodgement complications associated with
PICC lines and even midlines occur most often due to
improper anchoring of device.
 Any signs or symptoms of the following should be reported
immediately.
o leaking at catheter site,
o wet dressing,
o swelling,
o burning
 A catheter that migrates externally should never be re-
advanced into the vein.
o It should be stabilized at the point of external migration and
assessed for proper placement before further use.
o If catheter appears to have migrated a CXR may be indicated for
confirmation of placement.
 INS and NHIA recommend that site measurement and
external catheter length be routinely assessed,
documented and compared with insertion record at
regular intervals. It is suggested it be performed with
weekly dressing changes.
 Normal use of the accessed arm is needed to maintain
circulation however patients should be educated to
avoid:
o strenuous work
o lifting objects greater than 10 pounds
o repetitive motion
o swimming
 Per INS guidelines, PICC line removal should only be
performed on the order of a licensed independent practitioner.
 The nurse should be competent in the process for VAD
removal, including identification of potential complications,
and appropriate nursing interventions and/or emergency
measures as needed.
 A PICC should be removed upon unresolved complications,
therapy discontinuation, or if deemed unnecessary.
 The patient should be positioned so that the CVAD insertion
site is at or below the level of the heart to reduce the risk of air
embolus. Supine position is preferred
 Educate patient on Valsalva’s maneuver for all CVAD removal
procedures.
 INS recommendations for PICC line removal are as follows:
o Wash hands, use aseptic technique and observe standard
precautions.
o Remove stabilization device and dressing and disinfect catheter
skin junction.
o Using gentle even pressure, slowly retract catheter from site with
dominant hand while holding site with gauze as patient performs
Valsalva’s maneuver.
o After removal apply digital pressure to site until hemostasis is
achieved, a minimum of 30 seconds.
o Apply a petroleum based ointment dressing to seal the skin-to-vein
tract and decrease risk of air embolus. Change dressing every
24hrs until exit site is healed.
o Record length of CVAD removed and condition of tip. Compare with
original insertion record to ensure entire length of catheter was
removed.
o If resistance is met, do not attempt removal. Consider using
relaxation techniques if patient is anxious. Place a warm compress
or pack on arm for 15 minutes, then attempt again.
o If still unable to remove, notify physician.
PHOTO REFERENCE: http://www.bupa.co.uk/jahia/webdav/site/bupacouk/shared/Flash/Individual/health-information/factsheets/tunnelled-central-line/start-
image.jpg
RHOTO REFERENCE: http://images.ddccdn.com/cg/images/en141690.jpg
 A tunneled central venous catheter is a long silicone or
polyurethane tube open at each end.
 It is inserted into a central vein at one location (neck,
chest or groin) and tunneled under the skin to a separate
exit site, typically the chest. It exits the body several
inches away from the vein.
 A Dacron cuff, located and anchored just under the skin
at the exit site, provides stability and helps reduce risks
of infection.
 Though more comfortable and discreet for patients than
non-tunneled catheters, they still carry the same risks of
hemorrhage, pneumothorax, and infection.
 Infection rates are reported to be lower with tunneled
catheters verses non-tunneled catheters.
 With proper care a tunneled catheter can remain in place for
several years.
 Tunneled catheters are often referred to by their brand name,
o Hickman
o Hohn
o Broviac
o Leonard
o Neostar
o Groshong
 They are available in single, double and triple lumens
depending on brand.
 Tunneled catheters are generally surgically placed or placed
in radiology. In some facilities, highly trained infusion nurses
are also performing the procedure.
o As such, they are not able to be removed in the home.
 Typically tunneled catheters are placed for long term
therapy in patients with chronic illnesses or cancer.
 They can be used in:
o inpatient and outpatient settings for chemotherapy
o parenteral nutrition
o poor venous access
o Plasma pheresis
o dialysis
o other prolonged therapies
 Dialysis and plasma pheresis catheters are relatively
large bore catheters to allow for high flow rates whereas
smaller catheters may be used for infusion purposes.
 Care of a newly tunneled catheter follows the same guidelines
as other CVADs.
 Initial dressing should be changed in 24 hrs and then if using
a transparent semi permeable dressing (TSM), weekly and as
needed.
 If gauze dressing is used it should be changed every 2 days.
 Once healed, tunneled catheters may go without a dressing
with a prescriber order unless the patient is
immunocompromised.
 In most cases sutures may be removed from a tunneled
catheter insertion site 2-3 weeks after insertion with prescriber
order.
 Clean technique for dressing changes may be used 7-10 days
after sutures are removed from a newly tunneled CVAD.
 Flushing the tunneled catheter depends on the
manufacturers’ recommendations and in accordance
with the treating clinician’s orders.
 In general, Groshong, valved or closed tip catheters only
require 0.9% Sodium chloride unless otherwise
specified.
 Non-tunneled catheters are placed by physicians,
radiologists and other trained health care professionals
in an acute care setting.
 They are inserted by direct venipuncture into the internal
jugular, subclavian, and femoral veins.
 The risk of pneumothorax and other complications are
such that catheter placement needs to be in a setting
where emergency intervention is readily available.
 The risk of infection is significantly higher than that of
other CVADs due to the fact that bacterial count in the
area of insertion is much higher than other body areas.
 They are typically inserted for short tem use and are not
recommended for home use due to the higher
incidences of complications.
PHOTO REFERENCE: http://images.ddccdn.com/cg/images/en135134.jpg
PHOTO REFERENCE: http://faculty.mercer.edu/summervill_j/jeanchiang/Mvc-083s.jpg
PHOTO REFERENCE: http://jenneink.blogs.com/photos/uncategorized/port.jpg
 Implantable ports are implanted subcutaneously to
provide access to the peritoneal cavity or the vascular,
arterial, or epidural system.
 The use of implantable ports has grown tremendously
since their first use in 1981.
 Oncology patients were the first recipients of implanted
ports.
 Acceptance of these devices has grown rapidly with
more than 100,000 ports being implanted each year.
 More than fourteen different manufacturers have
designed their own type of port, yet most are similar in
design, function, and application.
 The implantable port consists of the portal body and the
catheter.
o The portal body is made of stainless steel, titanium, polysulfone, or
a combination thereof with an inner center space called a reservoir.
o Most catheters are made of silicone, as this material is known to
produce fewer thrombi.
 The three principal outside features of the I.P. are the base,
the shoulder, and the barb.
 A self-sealing, compressed silicone septum, overlays the
portal body.
 The septum is designed for either top and/or side access.
 Port access is done by an I.P. needle, Huber needle, or a
needle with a deflective, non-coring tip.
 Several commercially made ports are available in single or
double lumen designs.
 Lower profile (thinner) designs are available for smaller
 Like tunneled catheters, I.P’s are inserted in patients in need
of long term access generally greater than three years.
 Like tunneled catheters they are similarly used for patients
with
o chronic illnesses
o chemotherapy
o parenteral nutrition
o pain management
o frequent venous access
o blood components
o other long term therapies
 The advantage to having an IP is the absence of any external
component decreasing risk for breakage and infection.
 They are especially preferred among young active adults for
 An implanted port is surgically placed subcutaneously beneath the
skin, and generally in the chest region.
 The incision is made halfway between the clavicle and nipple on
either the left or right side of the chest.
 The right side of the chest is generally preferred because of its direct
path to the superior vena cava (SVC).
 The surgeon makes the final decision about the site for implantation
based on skin condition, presence of a pacemaker, and other
medical conditions that would contra-indicate the use of a particular
site.
 An approximate 5-cm incision in the skin is made at the selected
site.
 A pocket is created approximately two inches away from the incision
line and 0.5-cm to 2.0 cm deep into which the portal body is placed.
 The pocket is located away from the incision line in order to avoid
rupturing the incision with subsequent accessing of the port.
 The I.P. is placed in this pocket and sutured in place to the
 The catheter is threaded subcutaneously from a point near
the clavicle to meet with the portal body.
 The catheter tip is advanced into the subclavian vein and
terminated in the SVC/ right atrial junction.
o It takes approximately two weeks for the body to establish a healed
tract for the tunneled catheter.
 The procedure is done under local anesthesia and takes from
30-60 minutes.
 Placement of the smaller P.A.S. port in the arm can be done
in a doctor’s office.
 Other sites used for the placement of an I.P. are in the
abdominal cavity with the tip of the catheter tunneled into the
inferior vena cava (IVC).
 The breast may also be used for I.P. placement in female
patients.
 Chest placement provides best stability to the port when
accessed than does alternate locations.
 P.A.S. port, the Groshong port, the side-access port, and
the dome (or Omega) port are common brands
associated with IPs and some are available as single or
dual access.
 Port choice is primarily dependent upon the surgeon’s
choice or availability within a particular medical facility.
 Dual ports allow infusion of non-compatible medications
and fluids.
o Additional IV access increases the probability of complications such as phlebitis,
hematomas, and infiltration.
 The RN is often the patient’s advocate in helping them
choose the safest and most appropriate choice for
venous access devices.
 Dual I.P.s have separate reservoirs and separate catheters to
each reservoir; however the catheters are generally encased
in one sleeve.
o Each port requires individual care.
• If it is not clear whether a patient has a single or double port, palpate the
skin over the port, a double lumen will be rectangular with two septum’s, a
single lumen port will be round with one septum
o If each port of a dual lumen is accessed properly, two separate external
catheters will extend from the dressing site.
 The Groshong port is manufactured as a single or dual port.
o The tip of the Groshong I.P. catheter has valves typical of the
tunneled Groshong catheter.
o No heparin is required with the Groshong catheter because of these
valves.
 The Omega (or dome) port is shaped like a dome with a steel
mesh encasing the dome.
 The side access port is accessible from both sides of the port
body. A flat butterfly Huber needle is used to access these
ports
 Before accessing a patient’s I.P:
o Visually assess and palpate chest wall for complications of swelling and
pain.
o Assess for pain, or swelling in the shoulder, arms or fingers on port side
of body.
o Examine neck veins for any distention. Gently palpate catheter tract for
kinking or coiling, but only if catheter is visible under the skin.
o Palpate I.P. under skin and assess portal body for position and
observing for any unusual skin conditions over and around the IP.
o Report any unusual signs and symptoms to prescribing physician.
 The IP should be accessed with the smallest gauge non-
coring safety needle, or Huber needle, necessary to
accommodate the prescribed therapy.
 To reduce the risk of needle dislodgement while accessed, the
Huber needle should:
o be a length that allows the needle to make contact with the back of
the port when inserted and sit flush to the skin and secure within the
port.
 INS recommends replacement of non-coring needle every 7
days when left in place for continuous infusions.
 The type of I.P. needle used differs with each facility.
 Huber needles come in various length and gauge and with
and without catheters attached.
 Prior to use of an implanted port, patency should be confirmed by
presence of blood return and ability to flush the port with
preservative free 0.9% sodium chloride solution without evidence of
infiltration.
 When an IP is accessed, a TSM dressing or gauze dressing should
cover the needle and access site.
 If gauze is used to support the wings of an access needle under a
TSM dressing, it can be considered a TSM dressing and changed
every 7 days or when necessary per standards.
 Gauze dressings alone or that cover a site under a TSM dressing
are recommended to be changed every 2 days.
 The use of positive pressure during non-coring needle withdrawal
(de-accessing) should be used to reduce blood reflux and risks of
thrombotic catheter occlusion.
 INS recommendations for IP lock is 5mls of 100u/ml heparin before
de-accessing.
o Groshong-manufacturer recommends use of 0.9% preservative free sodium
chloride solution.
 Flushing a CVAD is not only critical to preserve function and
prevent infection, it ensures catheter patency before a
medication or IV solution is administered and after to prevent
precipitation.
 It is also necessary to flush between medication
administration to clear the catheter and avoid
incompatibilities.
 The minimum volume of 0.9% sodium chloride depends on
the type and size of the catheter, age of the patient, and
therapy being given.
 A nurse should aspirate for blood return before any
administration of medication or solutions; if resistance is met
and/or no blood return noted further steps should be taken to
assess patency before use.
 The catheter should never be forcibly flushed as this could
lead to catheter rupture.
 Patients and caregivers are not routinely taught to assess
patency via blood return.
 Always use a 10ml or larger syringe to flush or administer
medications. Smaller syringes have increased flushing pressure that
can cause catheter rupture.
 Turbulent flushing, an intermittent push-stop-push technique in
which a small amount of 0.9% Sodium chloride solution is quickly
injected then paused and repeated until the total amount of flush is
given is now the standard in proper flushing.
 This practice helps remove the build up of residue, medication and
fibrin that may have formed on the inner walls of the catheter.
 Even when not in use, CVADs must be flushed regularly to maintain
patency.
 There remains a lot of controversy and confusion surrounding
flushing protocols and standardization of care differs between
various health care settings.
 Manufacturer’s recommendations and institution or agency protocol
should be followed regarding amounts and intervals.
 INS recommendations for a CVAD in the Adult patient
are as follows:
o Flush before and after each medication with a minimum of 3-
5mls preservative free normal saline solution.
o Flush volume should be at least 2 times the internal volume of
the CVAD and all add on devices. (e.g., extension sets)
o Lock solution may be instilled as a final flush to maintain CVAD
patency; instill 2-3mls heparin 10u/ml when CVAD is not in use.
Implanted port uses 5mls 100u/ml heparin as a lock solution.
o Groshong-Manufacturer recommends 5 mls of normal saline
only-and flush weekly when not in use. Note: Valved CVAD’s
may require heparin when used long-term
o Flush/Lock CVAD at least once a day when not in use.
 Certain needless connectors contain devices that prevent the
backflow of blood and hence eliminate the need for heparin.
 Heparin should be avoided in patients who are allergic, have
clotting disorders, have a history or develop
thrombocytopenia.
 When a 0.9% Sodium chloride solution is incompatible with a
medication being administered, a 5% Dextrose in water flush
should be used before and after, followed by a 0.9% sodium
chloride flush, and then heparin lock if indicated.
o Dextrose solution should always be flushed from the catheter because
it can provide nutrients for biofilm growth.
 Pediatric guidelines for flushing may vary and should be
followed per MD order agency protocol.
Device Intermittent Parentera Blood Blood Draws Flushing with No Heparin Locking
l Product Therapy
Nutrition Administratio
n
PIV Min 2 ml NA Preadmin 2 NA At least q 12 hours NA
ml
Postadmin 10
ml
Midline Min 3 ml NA Preadmin 3 NA At least q 12 hours 3 ml 10 units/ ml heparin
ml
Postadmin 10
ml
PICC Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least q 5 ml 10 units/ ml heparin
ml Postdraw 10 24 hours
Postadmin 10 ml Valved – at least
ml weekly
Non- Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least q 5 ml 10 units/ ml heparin
Tunnell ml Postdraw 10 24 hours
ed Postadmin 10 ml Valved – at least
ml weekly
Tunnell Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least 1- 5 ml 10 units/ ml heparin
ed ml Postdraw 10 2 times per week
Postadmin 10 ml Valved – at least
ml weekly
Port Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Accessed Nonvalved – 3-5 ml 10 units/ ml heparin
Reference: INS Guidelines T able for flushing ml Postdraw 10 at least 1-2 time per
Device APV-
approximate
priming
volume
Locked Device:
Volume, Frequency
And Solution
All saline should be
preservative-free
Medications: Pre- and Post-
Administration
Administration system/ methods
include: large volume pump, gravity set,
syringe pump method, and IV push.
The unique tubing configurations used
in this population and volume contained
prohibit standardization of flush
volumes.
Blood Product Administration and Sampling
Withdrawal Volume for Blood Sampling Accuracy
Peripheral IV
APV
0.05-0.07 ml
NICU Patients: 1 ml
NS every 6 hours
Pediatrics: 1-3 ml NS
every 8 hours
2 times administration tubing and add-
on set volume
Pre- and post-blood administration: 1-3 ml NS
NA for routine sampling: for short-term studies follow locked
device protocol, discard 1.5 ml for short-term studies from PIV
dedicated to sampling
Short
peripheral
Arterial APV
0.05-0.07 ml
NA NA for medication administration Pre- and post-blood administration: NA
Withdrawal volume for sampling:
Stopcock Method: 1.6 ml
Closed blood sampling system: refer to manufacturer
recommendations
Post Sampling: up to 1 ml NS or heparinized saline solution in
24-guage catheters and until clear for all other catheters
Umbilical
Catheter
APV each
lumen 0.15-
0.32 ml
Umbilical Venous
Catheter (UVC):
Umbilical Arterial
Catheter (UAC):
typically not locked
1 ml saline solution or heparinized
saline solution with <1 unit/ml heparin,
or 2 times administration tubing and
add-on set volume
Pre- and post-blood administration: 1 ml NS or 1 ml NS + <1
unit/ml heparin and until clear
Withdrawal volume for sampling when using a stopcock on
catheter hub: 1.6 ml
Closed blood-sampling system: refer to manufacturer
recommendations
Midline
APVs
[mls]
3 F-0.16
4 F-0.19
2F: 1 ml NS + 10
units/ml heparin every 6
hours
2.6F and larger: 2-3 ml
NS + 10 units/ml
2 times administration tubing and add-
on set volume
Pre- and post-blood administration: 1-3 ml NS followed by
locking solution or resume infusion.
NA for routine sampling: for short-term studies follow locked
device protocol, discard 1.5 ml for short-term studies from
midline dedicated to sampling
5 F-0.22 heparin every 12 hours
Device APV-
approximate
priming volume
Locked Device:
Volume,
Frequency
And Solution
Medications: Pre- and Post-
Administration
Blood Product Administration and Sampling
Withdrawal Volume for Blood Sampling Accuracy
PICC APVs
1.9 F.: 0.06 ml
3-3.5 F: 0.2-0.5ml
4 F: 0.06 ml
5 F: 0.4-0.8 ml
6 F: 0.5-0.6 ml
2F: 1 ml NS + 10
units/ ml heparin
every 6 hours
2.6 F and larger:
2-3 ml NS + 10
units/ml heparin
every 12 hours
2 times administration tubing and add-
on set volume
2 F Sampling and pre- and post-blood administration: 1 ml
to clear the catheter, then flush with 1ml NS followed by locking
solution until clear
2.6 F and larger sampling and pre- and post-blood
administration:
1-3 ml NS followed by locking solution or resume infusion
Withdrawal volume: 3 times administration tubing and add-on
set volume
Tunneled and
Non-Tunneled
APVs:
2-3 F 0.12-0.15 ml
4 F 0.3 ml
5 F 0.5 ml
6 F 0.6-0.8 ml
7 F 0.6-0.9 ml
9 F 0.6-1.3 ml
NICU Patients: 1-
3 ml NS + 10
units/ ml heparin
ever 12-24 hours
Pediatrics: 2 ml
NS + 10 units/ ml
heparin every 24
hours
2 times administration tubing and add-
on set volume
Pre- and post-blood administration: 1 ml for NICU patients
and 3 ml for all others of NS followed by locking solution or
resume infusion
Withdrawal volume for sampling: 3 times administration
tubing and add-on set volume. Variation in size makes it difficult
to recommend one volume for all patients.
Ports APVs If used for more
than 1
medication daily:
3-5 ml NS + 10
units/ml heparin
Monthly
maintenance
flush: 3-5 ml NS
+ 100 units/ ml
l
heparin
le for flushing
ines Tab
2 times administration tubing and add- Pre- and post-blood administration: 3-5 ml NS followed by
[mls] on set volume locking solution or resume infusion.
0.8 mm I.D.: 0.8 Withdrawal volume for sampling : 3 times administration
1.0 mm I.D.: 1.1- tubing and add-on set volume. Variation in size makes it difficult
1.2 to recommend one volume for all patients.
1.1 mm I.D.: 1.2
1.4 mm I.D.: 1.7
1.6 mm I.D.: 2
Reference: INS Guide
Reference: INS Guidelines Table for flushing
NACL Dextrose Heparin Heparin, Cont.
GENERIC BRAND GENERIC BRAND GENERIC BRAND GENERIC BRAND
Aldesleukin Proleukin ® Baclofen Lioresal® Alteplase Activase® GentamicinSlulfate
Amphotericin B
CholesterylSulfate Amphotec® Bupivicaine Marcaine® Amikacin Haloperidol Decancate
Haldol
Decanoate®
Amphotericin B
Deoxychoate Fungizone® Cladribine Leustatin® Amobertibal Sodium Amytal® Haloperidol Lactate Haldol®
Amphotericin B Lipid
Complex Abelcet® Clonidine Duraclon®
Amphotericin B Cholesteryl
Sulfate Amphotec® Hyaluronidase Hydase®
Amphotericin B
Liposomal AmBiosome® Dantrolene Dantrium®
Amphotericin B
Deoxychoate Fungizone®
Hydrocortisone Sodium
Phospate Solu-CorteF®
Dantrolene Sodium Dantrium® Daptomycin Cubicin® Atropine Hydroxyizine HCl
Daunerubicin Lipsomal DaunoXme® Dihydroergotamine DHE-45® Cefmatazole Idarubicin
Dihydroergotamine
Mesylate DHE-45® Interferon alpha 2 Intron®A Chlordiazepoxide Librium® Kanamycin Sulfate
Epoetin Alfa Procrit®,Epogen® Intraconazole Sporanox® Ciprofloxacin Cipro® Levofloxacin Levaquin®
Filgrastim Neupogen® Levothyroxine Sodium Synthroid® Clarithromycin Biaxin® Levorphanol Tartrate Levo-Dromoran®
Immune Globulin Bammunex® Methadone HCl Dolophine® Codeine Methylprednisolone Solu-Medrol®
Liposomal Doxorubicin Doxil® Phenytain Dilantin® Cytarabine Tarabine® Mitoxantrene HCl Novantrone®
Methoxamine Vasexyl® Streptomycin Streptomycin Daunorbucin Hcl Cerubidine® Morphine Sulfate
Mycophenolate Mofetil
HCl CellCapt® Tenecteplase TNKase® Diazepam Valium® Nesiritide Natrecor®
Nitroprusside Nitropress® TreprostinilSodium Remodulin® Dexorubicin HCl Adriamycin® Norepinephrine Bitartrate Levophed®
Norepinephrine Levophen® Doxycycline Hyclate Orphenadrine Citrate
Oxaliplatin Eloxatin® Droperidol Inapsine® Pentamidine
Propafenone Rythmol Dretrecoginalfa Xigris® Phenytoin Sodium Dilantin®
Propofol Diprivan® ErgonovineMaleate Methergine® Polymyxin B Sulfate
Quinupristin/ Dalfopristin Synercid® ErythromycinLacte Prochlorperazine Edisylate Compazine®
TrimetrexateGlucuronate Neutrexin® Filgrastim Nuepogen® PromethazineHCl Phenergan®
Quinupristin/ Dalfoprisitin Synercid®
Reference: INS Guidelines Table for flushing
 INS and NHIA recommendations for lab draws for the adult
patient are as follows:
o Stop all infusions prior to blood sampling and flush the VAD with 10-
20mls preservative free 0.9% sodium chloride.
o Discard the first 5mls blood drawn unless using for blood culture.
o Remove cap/needleless connector before obtaining blood sample
for culture, and include all blood drawn in the specimen. (no
discard)
o Flush with 10-20mls normal saline immediately following any lab
draw, followed by lock solution if CVAD will not be in use.
o For multi-lumen CVADs the sample should be drawn from the distal
most lumen; (or lumen recommended by manufacturer) for drug
level sampling, use the lumen not being used for the drug infusion.
o Only the volume of blood needed for accurate testing should be
obtained.
 Pediatric guidelines vary between institution and agency and
should be followed as such.
 Hand hygiene is the #1 prevention in health associated infections (HAI).
CDC guidelines for hand hygiene should be followed to decontaminate
hands prior to contact with any aspect of the CVAD.
 Recommendations from CDC and INS are for CVAD dressing changes
24-48 hours after insertion then a minimum of every seven days or
when becomes wet, soiled, or loses it’s integrity.
 If a gauze dressing is being utilized, all edges should be secured with
tape.
 The recommendation for a gauze dressing is to change it every 2 days.
 Sterile gloves and face mask should always be worn when performing
CVAD dressing site care.
 Chlorhexedine solution, except in infants under 2 months of age, is the
preferred skin antisepsis for VAD site care though a combination of 1-
2% tincture of iodine, povidone iodine and/or 70% alcohol may be used.
 Apply all antiseptics to the skin with friction (scrubbing motion) to
penetrate epidermal layers, even if applying in a circular motion from
exit site outward. When alcohol/povidone combination is being used,
alcohol scrub should precede the povidone scrub.
 Allow all antiseptics (and skin protectants if used) to dry completely and
naturally before applying dressing.
 Caregivers may or may not be instructed in actual
dressing change procedure, as it varies within
organizational policy.
 CVADS should not have any antibiotic ointments applied
to insertion site due to potential for promoting infection
and antimicrobial resistance.
 Hub antisepsis is an important step in preventing
microorganisms being transferred into the catheter
lumen.
o A 15-second scrub using friction with alcohol or
chlorhexidine/alcohol to the needless connector/hub has been
shown to prohibit microorganism entry on the surface.
o It must be performed prior to every access of the catheter. For
example, if using the SASH procedure to flush the CVAD
this means 4 alcohol pads, one before each of the four
steps in the procedure and allowing alcohol to dry prior to
 As with any vascular access device, there are risks and
complications associated with placement.
 Air embolism: Air bubbles may enter the bloodstream during
insertion, while in place, or upon removal.
o Healthcare professionals, patients and caregivers must be educated
in the prevention and signs and symptoms including:
• tachycardia
• lightheadedness
• anxiety
• confusion
• palpitations
• difficulty breathing
• coughing
• hypotension
o EMS must be activated immediately and patient should be
instructed to lie down on left side with feet elevated until emergency
personnel arrive.
 Phlebitis: Inflammation of the internal aspect of the vein. Symptoms include:
• redness
• pain at access site
• streak formation
• palpable venous cord
o Nurse or physician must be notified so measures can be taken.
 The three main causes of phlebitis are namely, mechanical, chemical and
infective or bacterial phlebitis.
o Mechanical phlebitis can occur during insertion or from repeated manipulation of
the device.
• Adequate securement of the catheter and use of warm heat can reduce the friction and
inflammation; however signs and symptoms that persists may need further intervention.
o Chemical phlebitis occurs when irritating drugs or solutions are administered
through the catheter damaging the vessel.
• Alternate VAD device may need inserted depending on therapy.
o Infective phlebitis is caused from bacteria.
• A localized infection may be treated with frequent dressing changes and antibiotics however a
positive bacterial culture from the catheter or exit site may warrant removal.
Grade Clinical Criteria
0 No Clinical Symptoms
1 Erythema at access site with or without pain
2 Pain at access site with erythema and/ or edema
3 Pain at access site with erythema , streak formation, and/ or
palpable venous cord
4 Pain at access site with erythema , streak formation, palpable
venous cord >1 inch in length, and /or purulent drainage
Phlebitis Scale
Reference: Box 23-5 Infiltration Scale. Page 472 Infusion Nurses Book.
 Infection: May develop either inside the vessel or at the
insertion site.
o Site should be inspected daily for any redness, pain, swelling,
pus-like drainage or fever and chills and should contact the
nurse or MD immediately if develops.
o Typically the source is directly related to the dressing covering
the site and often due to a dressing becoming wet.
o Once wet, moisture and body heat become an ideal breeding
ground for bacteria.
o Patients/caregivers must be educated to report wet, soiled or
compromised dressings.
 Occlusion: A catheter that becomes sluggish and difficult to
flush, or unable to flush could indicate a partial or total
occlusion.
o Intraluminal occlusions occur as a result of blood clot formation
within the catheter, medication incompatibilities or precipitates.
o Extraluminal occlusions result from formation of distal fibrin sheath,
catheter malposition, or mechanical obstruction (kinking).
o Factors that predispose a catheter to occlusion are multiple infusion
therapies, frequent blood sampling and improper flushing.
o The patient/caregiver should be instructed to contact the nurse or
physician for troubleshooting or early intervention.
o Catheter should be assessed appropriately, and managed
accordingly.
o Use of an anti-thrombolytic agent may be indicated to prevent
disruption of therapy and prevent further complications.
• Anti-thrombolytic agents such as Cathflo can be used in midlines and CVADs when
 Migration/dislodgement and damage: This occurs most
often due to improper anchoring of device or excessive
pressure when flushing the CVAD.
o Any signs or symptoms of leaking at catheter site, wet dressing,
swelling, burning, or pain in the arm, shoulder or neck should be
reported.
o Patient should be instructed to stop using the catheter and, if
there is a visible crack or leak, apply a clamp above the site
close to the catheters exit site, if possible.
o Catheter repair kits are available but not routinely available for
home use due to the many different manufacturers and types of
CVADs.
o Notify nurse/physician immediately.
 Although the home care nurse provides expert clinical
assessment, judgment and care to the CVAD, the patients
and caregivers are ultimately responsible for the day to day
care of the CVAD.
 Patient education becomes a critical intervention in safe and
reliable home infusion therapy and CVAD care.
 Many factors, physically and mentally, affecting patients or
caregivers ability and readiness to learn must be assessed
and routinely evaluated.
 Aseptic technique and hand hygiene should be repeatedly
reinforced, demonstrated and observed.
 Patients and caregivers should be taught to inspect the site
and dressing daily for any irregularities and given clear and
simple instructions about what and when report.
1. INS: Infusion Nursing Standards of Practice. Nursing Journal of Infusion 2011; 34, (1S) S37-S68
2. Hadaway, L. INS: Journal of Infusion Nursing: Short Peripheral Intravenous catheters and Infections 2012; 35(4) 230-235.
3. Carlos do Rego Furtado, L. INS: Journal of Infusion Nursing. Maintenance of Peripheral Venous Access and Its Impact on the Development of Phlebitis 2011;34 (6) 382-389
4. Dychter, S, Gold, D, Carson, D, Haller, M. INS: Journal of Infusion Nursing. Intravenous Therapy 2012; 35 (2) 84-91
5. Perucca, R. INS: Infusion Nursing, an Evidence Based Approach: Peripheral Venous Access Devices: Chapter 23 pp 456-479
6. NHIA: Central vascular guidelines for the Adult home based patient 6/25/11
7. INS: Policies and Procedures for Infusion Nursing 3rd edition. 84-102, 124-132
8. Lyons, M, Phalen, A. NHIA Infusion. An Evidentiary Review of Flushing Protocols in Home Care Patients with Peripherally Inserted Central Catheters 2012; 18(5) 32-40
9. Kramer, N Leone, M, Ross, K, Shaps, F, Cain, D. NHIA Infusion. CVAD Guidelines for Home Infusion. 2011; 17 (4)29-36
10. Hadaway, L. Targeting Therapy with CVAD: Nursing: 2008; 38(6) 35-40
11. Hufcut, T. Choosing an Effective and safe Central Venous catheter. An Evidence based Approach. Picclinenursing.com
12. Seigel, M. Kraemer-Cain, J. PICC Line Care at Home. Advance for Nurses. Nursing.advanceweb.com
13. Funaki, B. AJR Review. Central Venous Access: A Primer for the Diagnostic Radiologist. 2002; 179 (2)
14. Gorski, L. Home Healthcare Nurse. Central Venous Access Device Associated Infections: Recommendations for Best Practice in Home Infusion Therapy. 2010; 28(4) 221-229
15. CDC: Healthcare Associated Infections.(HAIs) Basic infection Control and Prevention Plan for Outpatient Oncology Settings
16. Bullock-Corkhill, M. INS: Infusion Nursing, an Evidence Based Approach: Central Venous Access Devices: Access and Insertion Approach, Chapter 24: 480-493
17.http://nursinglink.monster.com/training/articles/302-the-use-and-maintenance-of-implanted-port-vascular-access-devices
www.journalofinfusionnursing.com
18.http://infonet2.upmc.com/OurOrganization/Enterprise/Quality/Infection/Pages/Central-Line-Toolkit.aspx

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chemotherapy access device.pptx

  • 2.  Central Venous catheters or access devices can be categorized into four groups based on their design: o peripherally inserted central catheters o temporary (non-tunneled) central venous catheters o permanent (tunneled) central venous catheters o implantable ports.  Although tip location of all central lines may be the same, insertion sites may vary.  It is the responsibility of the Nurse to be knowledgeable of the CVADs design, purpose, limitations, and precautions and to educate patients and caregivers so they can independently manage their catheters whether in an inpatient, outpatient or homecare setting.
  • 3. PHOTO REFERENCE: http://www.utmedicalcenter.org/lib/image/manager/pages/departments/radiology/radiology-patient-services/picc-team- service/picchome1_opt.jpg PHOTO REFERENCE: http://t1.gstatic.com/images?q=tbn:ANd9GcQmispXuKKSH9j2lAiEvPRIp35n8bg2u8WC0EEP9QDA0yNem5849s-vK2fY
  • 4.  By definition, and per its’ acronym, A PICC line is a peripherally inserted central catheter.  It is a long (approx. 50cm or 20 inches) slender flexible tube that is inserted into a peripheral vein, typically in the upper arm of adults and children and sometimes the scalp and lower extremity of pediatric patients.  The PICC is then threaded along the vein into the subclavian and eventually into the vena cava and central circulation.  The Registered Nurse should understand that a PICC is a central venous access device (CVAD) which requires the same care as other central venous catheters to avoid complications and achieve positive patient outcomes.
  • 5.  In many Hospitals and outpatient settings the PICC line has become the preferred alternative to central lines due to cost effectiveness, ease of insertion and significant lower incidence of major complications.  Specially trained and certified nursing teams have been effectively placing PICCs at the bedside, thereby decreasing costs and enhancing patient comfort.  Major complications such as hemothorax, pneumothorax, and vessel rupture are not typically present with PICC insertion.  In addition risk of infection is greatly reduced due to the mere placement of the line: upper arm, verses neck or chest for central line.
  • 6.  PICC lines are commonly used in acute care settings, homecare settings and skilled nursing facilities for a variety of therapies.  They are used for short term therapies of only 1 week to long term therapies up to 1 year.  Some of the various indications are: o chemotherapy, o parenteral nutrition o repeated blood or blood products o frequent venous sampling in those with poor venous access o Central venous pressure monitoring in various critical care areas Any infusate, regardless of osmolarity, pH, or other chemical properties of a solution or medication can be administered via PICC line. o INS guidelines state that drugs which have a pH less than 5 and
  • 7.  PICC lines are typically made of polyurethane and silicone.  They typically range in size from 4-7 French, but can be as small as 1.1 French for neonates.  Due to the increasing need for high-pressure injection for CT Scans, the use of polyurethane PICCs (Power) are increasing.  Single, double and triple lumen PICCs are available.
  • 8.  PICC lines are generally classified into either open ended or valved.  An open ended catheter is generally maintained with a Heparin lock solution because of blood reflux into the catheter tip.  With a valved catheter, a valve is built into the internal tip or external hub. o The valve prevents blood from the vessel from inadvertently entering the catheter.  While these valves have different designs and function in different ways, the one common aspect is the fact that they can be flushed and locked with 0.9% Normal Saline solution only and do not require heparin.  Examples of these types of valved catheters are the o Groshong Catheter o Bard Solo PICC o Vaxcel PASV
  • 9.  PICC line placement can be done in both the inpatient and outpatient setting and is performed by trained and qualified health care professionals such as : o Radiologists o Physician assistants and certified o Certified Registered Nurses.  The Basilic vein is preferred because of its large diameter; however the Cephalic vein can be used.  Least preferred are the Brachial veins due to increased risk of complications.
  • 10.  There are 2 techniques commonly used to insert a PICC line. o The Peel Away Cannula Technique is performed by feel only and then advanced and confirmed under fluoroscopy. o The second technique known as the Modified Seldinger Technique involves ultrasound guidance to visualize the vessels in the upper arm then placement confirmation via fluoroscopy or chest x-ray.  Latest technology now combines ultrasound for vein access, magnetic tip location, and electrocardiographic (EKG) guided positioning for final tip confirmation. o This method prevents patient’s exposure to radiation and saves time in repositioning catheter in the case of previous malposition.
  • 11.  Arm circumference at the insertion site should be measured at time of insertion and recorded for future use to identify swelling that may not be accompanied by erythema.  Catheter measurements should also be documented in the patient record. o They should include total length, and external length.  Insertion measurements are necessary for PICC removal and ongoing assessment.  Accessed arm should not be used for phlebotomy or Blood pressure measurement.
  • 12.  National Standards of practice, FDA, and CVAD manufacturers recommend placement of the PICC tip terminating in the distal end of the superior vena cava (SVC) at or near its junction with the right atrium.  The Infusion Nursing Standards of Practice recommends that all members of the Health care team collaboratively address CVAD tip location if the SVC is not used.  Nerve injury or irritation can be a complication during insertion of a PICC line, nearby nerves may get injured or irritated.  Signs and symptoms include: o shooting pains down the arm o numbness and tingling o sensation of pins and needles o weakness or in extreme cases paralysis. Though an uncommon complication it is occurs most when the brachial vein is selected.
  • 13.  INS guidelines no longer list dressings as stabilization devices.  CVADS should be secured to minimize movement in and out of the insertion site.  A manufactured catheter securement device is now the preferred alternative to tape or sutures when feasible.  These devices help reduce catheter dislodgement and the need for removal and reinsertion.  The chosen device should allow for assessment of catheter insertion site and should not alter the flow of fluid through the catheter.
  • 14.  The securement device should be changed with the weekly dressing change or when loose or soiled.  Migration and dislodgement complications associated with PICC lines and even midlines occur most often due to improper anchoring of device.  Any signs or symptoms of the following should be reported immediately. o leaking at catheter site, o wet dressing, o swelling, o burning  A catheter that migrates externally should never be re- advanced into the vein. o It should be stabilized at the point of external migration and assessed for proper placement before further use. o If catheter appears to have migrated a CXR may be indicated for confirmation of placement.
  • 15.  INS and NHIA recommend that site measurement and external catheter length be routinely assessed, documented and compared with insertion record at regular intervals. It is suggested it be performed with weekly dressing changes.  Normal use of the accessed arm is needed to maintain circulation however patients should be educated to avoid: o strenuous work o lifting objects greater than 10 pounds o repetitive motion o swimming
  • 16.  Per INS guidelines, PICC line removal should only be performed on the order of a licensed independent practitioner.  The nurse should be competent in the process for VAD removal, including identification of potential complications, and appropriate nursing interventions and/or emergency measures as needed.  A PICC should be removed upon unresolved complications, therapy discontinuation, or if deemed unnecessary.  The patient should be positioned so that the CVAD insertion site is at or below the level of the heart to reduce the risk of air embolus. Supine position is preferred  Educate patient on Valsalva’s maneuver for all CVAD removal procedures.
  • 17.  INS recommendations for PICC line removal are as follows: o Wash hands, use aseptic technique and observe standard precautions. o Remove stabilization device and dressing and disinfect catheter skin junction. o Using gentle even pressure, slowly retract catheter from site with dominant hand while holding site with gauze as patient performs Valsalva’s maneuver. o After removal apply digital pressure to site until hemostasis is achieved, a minimum of 30 seconds. o Apply a petroleum based ointment dressing to seal the skin-to-vein tract and decrease risk of air embolus. Change dressing every 24hrs until exit site is healed. o Record length of CVAD removed and condition of tip. Compare with original insertion record to ensure entire length of catheter was removed. o If resistance is met, do not attempt removal. Consider using relaxation techniques if patient is anxious. Place a warm compress or pack on arm for 15 minutes, then attempt again. o If still unable to remove, notify physician.
  • 19.  A tunneled central venous catheter is a long silicone or polyurethane tube open at each end.  It is inserted into a central vein at one location (neck, chest or groin) and tunneled under the skin to a separate exit site, typically the chest. It exits the body several inches away from the vein.  A Dacron cuff, located and anchored just under the skin at the exit site, provides stability and helps reduce risks of infection.  Though more comfortable and discreet for patients than non-tunneled catheters, they still carry the same risks of hemorrhage, pneumothorax, and infection.
  • 20.  Infection rates are reported to be lower with tunneled catheters verses non-tunneled catheters.  With proper care a tunneled catheter can remain in place for several years.  Tunneled catheters are often referred to by their brand name, o Hickman o Hohn o Broviac o Leonard o Neostar o Groshong  They are available in single, double and triple lumens depending on brand.  Tunneled catheters are generally surgically placed or placed in radiology. In some facilities, highly trained infusion nurses are also performing the procedure. o As such, they are not able to be removed in the home.
  • 21.  Typically tunneled catheters are placed for long term therapy in patients with chronic illnesses or cancer.  They can be used in: o inpatient and outpatient settings for chemotherapy o parenteral nutrition o poor venous access o Plasma pheresis o dialysis o other prolonged therapies  Dialysis and plasma pheresis catheters are relatively large bore catheters to allow for high flow rates whereas smaller catheters may be used for infusion purposes.
  • 22.  Care of a newly tunneled catheter follows the same guidelines as other CVADs.  Initial dressing should be changed in 24 hrs and then if using a transparent semi permeable dressing (TSM), weekly and as needed.  If gauze dressing is used it should be changed every 2 days.  Once healed, tunneled catheters may go without a dressing with a prescriber order unless the patient is immunocompromised.  In most cases sutures may be removed from a tunneled catheter insertion site 2-3 weeks after insertion with prescriber order.  Clean technique for dressing changes may be used 7-10 days after sutures are removed from a newly tunneled CVAD.
  • 23.  Flushing the tunneled catheter depends on the manufacturers’ recommendations and in accordance with the treating clinician’s orders.  In general, Groshong, valved or closed tip catheters only require 0.9% Sodium chloride unless otherwise specified.
  • 24.  Non-tunneled catheters are placed by physicians, radiologists and other trained health care professionals in an acute care setting.  They are inserted by direct venipuncture into the internal jugular, subclavian, and femoral veins.  The risk of pneumothorax and other complications are such that catheter placement needs to be in a setting where emergency intervention is readily available.  The risk of infection is significantly higher than that of other CVADs due to the fact that bacterial count in the area of insertion is much higher than other body areas.  They are typically inserted for short tem use and are not recommended for home use due to the higher incidences of complications.
  • 25. PHOTO REFERENCE: http://images.ddccdn.com/cg/images/en135134.jpg PHOTO REFERENCE: http://faculty.mercer.edu/summervill_j/jeanchiang/Mvc-083s.jpg PHOTO REFERENCE: http://jenneink.blogs.com/photos/uncategorized/port.jpg
  • 26.  Implantable ports are implanted subcutaneously to provide access to the peritoneal cavity or the vascular, arterial, or epidural system.  The use of implantable ports has grown tremendously since their first use in 1981.  Oncology patients were the first recipients of implanted ports.  Acceptance of these devices has grown rapidly with more than 100,000 ports being implanted each year.  More than fourteen different manufacturers have designed their own type of port, yet most are similar in design, function, and application.
  • 27.  The implantable port consists of the portal body and the catheter. o The portal body is made of stainless steel, titanium, polysulfone, or a combination thereof with an inner center space called a reservoir. o Most catheters are made of silicone, as this material is known to produce fewer thrombi.  The three principal outside features of the I.P. are the base, the shoulder, and the barb.  A self-sealing, compressed silicone septum, overlays the portal body.  The septum is designed for either top and/or side access.  Port access is done by an I.P. needle, Huber needle, or a needle with a deflective, non-coring tip.  Several commercially made ports are available in single or double lumen designs.  Lower profile (thinner) designs are available for smaller
  • 28.  Like tunneled catheters, I.P’s are inserted in patients in need of long term access generally greater than three years.  Like tunneled catheters they are similarly used for patients with o chronic illnesses o chemotherapy o parenteral nutrition o pain management o frequent venous access o blood components o other long term therapies  The advantage to having an IP is the absence of any external component decreasing risk for breakage and infection.  They are especially preferred among young active adults for
  • 29.  An implanted port is surgically placed subcutaneously beneath the skin, and generally in the chest region.  The incision is made halfway between the clavicle and nipple on either the left or right side of the chest.  The right side of the chest is generally preferred because of its direct path to the superior vena cava (SVC).  The surgeon makes the final decision about the site for implantation based on skin condition, presence of a pacemaker, and other medical conditions that would contra-indicate the use of a particular site.  An approximate 5-cm incision in the skin is made at the selected site.  A pocket is created approximately two inches away from the incision line and 0.5-cm to 2.0 cm deep into which the portal body is placed.  The pocket is located away from the incision line in order to avoid rupturing the incision with subsequent accessing of the port.  The I.P. is placed in this pocket and sutured in place to the
  • 30.  The catheter is threaded subcutaneously from a point near the clavicle to meet with the portal body.  The catheter tip is advanced into the subclavian vein and terminated in the SVC/ right atrial junction. o It takes approximately two weeks for the body to establish a healed tract for the tunneled catheter.  The procedure is done under local anesthesia and takes from 30-60 minutes.  Placement of the smaller P.A.S. port in the arm can be done in a doctor’s office.  Other sites used for the placement of an I.P. are in the abdominal cavity with the tip of the catheter tunneled into the inferior vena cava (IVC).  The breast may also be used for I.P. placement in female patients.  Chest placement provides best stability to the port when accessed than does alternate locations.
  • 31.  P.A.S. port, the Groshong port, the side-access port, and the dome (or Omega) port are common brands associated with IPs and some are available as single or dual access.  Port choice is primarily dependent upon the surgeon’s choice or availability within a particular medical facility.  Dual ports allow infusion of non-compatible medications and fluids. o Additional IV access increases the probability of complications such as phlebitis, hematomas, and infiltration.  The RN is often the patient’s advocate in helping them choose the safest and most appropriate choice for venous access devices.
  • 32.  Dual I.P.s have separate reservoirs and separate catheters to each reservoir; however the catheters are generally encased in one sleeve. o Each port requires individual care. • If it is not clear whether a patient has a single or double port, palpate the skin over the port, a double lumen will be rectangular with two septum’s, a single lumen port will be round with one septum o If each port of a dual lumen is accessed properly, two separate external catheters will extend from the dressing site.  The Groshong port is manufactured as a single or dual port. o The tip of the Groshong I.P. catheter has valves typical of the tunneled Groshong catheter. o No heparin is required with the Groshong catheter because of these valves.  The Omega (or dome) port is shaped like a dome with a steel mesh encasing the dome.  The side access port is accessible from both sides of the port body. A flat butterfly Huber needle is used to access these ports
  • 33.  Before accessing a patient’s I.P: o Visually assess and palpate chest wall for complications of swelling and pain. o Assess for pain, or swelling in the shoulder, arms or fingers on port side of body. o Examine neck veins for any distention. Gently palpate catheter tract for kinking or coiling, but only if catheter is visible under the skin. o Palpate I.P. under skin and assess portal body for position and observing for any unusual skin conditions over and around the IP. o Report any unusual signs and symptoms to prescribing physician.
  • 34.  The IP should be accessed with the smallest gauge non- coring safety needle, or Huber needle, necessary to accommodate the prescribed therapy.  To reduce the risk of needle dislodgement while accessed, the Huber needle should: o be a length that allows the needle to make contact with the back of the port when inserted and sit flush to the skin and secure within the port.  INS recommends replacement of non-coring needle every 7 days when left in place for continuous infusions.  The type of I.P. needle used differs with each facility.  Huber needles come in various length and gauge and with and without catheters attached.
  • 35.  Prior to use of an implanted port, patency should be confirmed by presence of blood return and ability to flush the port with preservative free 0.9% sodium chloride solution without evidence of infiltration.  When an IP is accessed, a TSM dressing or gauze dressing should cover the needle and access site.  If gauze is used to support the wings of an access needle under a TSM dressing, it can be considered a TSM dressing and changed every 7 days or when necessary per standards.  Gauze dressings alone or that cover a site under a TSM dressing are recommended to be changed every 2 days.  The use of positive pressure during non-coring needle withdrawal (de-accessing) should be used to reduce blood reflux and risks of thrombotic catheter occlusion.  INS recommendations for IP lock is 5mls of 100u/ml heparin before de-accessing. o Groshong-manufacturer recommends use of 0.9% preservative free sodium chloride solution.
  • 36.  Flushing a CVAD is not only critical to preserve function and prevent infection, it ensures catheter patency before a medication or IV solution is administered and after to prevent precipitation.  It is also necessary to flush between medication administration to clear the catheter and avoid incompatibilities.  The minimum volume of 0.9% sodium chloride depends on the type and size of the catheter, age of the patient, and therapy being given.  A nurse should aspirate for blood return before any administration of medication or solutions; if resistance is met and/or no blood return noted further steps should be taken to assess patency before use.  The catheter should never be forcibly flushed as this could lead to catheter rupture.  Patients and caregivers are not routinely taught to assess patency via blood return.
  • 37.  Always use a 10ml or larger syringe to flush or administer medications. Smaller syringes have increased flushing pressure that can cause catheter rupture.  Turbulent flushing, an intermittent push-stop-push technique in which a small amount of 0.9% Sodium chloride solution is quickly injected then paused and repeated until the total amount of flush is given is now the standard in proper flushing.  This practice helps remove the build up of residue, medication and fibrin that may have formed on the inner walls of the catheter.  Even when not in use, CVADs must be flushed regularly to maintain patency.  There remains a lot of controversy and confusion surrounding flushing protocols and standardization of care differs between various health care settings.  Manufacturer’s recommendations and institution or agency protocol should be followed regarding amounts and intervals.
  • 38.  INS recommendations for a CVAD in the Adult patient are as follows: o Flush before and after each medication with a minimum of 3- 5mls preservative free normal saline solution. o Flush volume should be at least 2 times the internal volume of the CVAD and all add on devices. (e.g., extension sets) o Lock solution may be instilled as a final flush to maintain CVAD patency; instill 2-3mls heparin 10u/ml when CVAD is not in use. Implanted port uses 5mls 100u/ml heparin as a lock solution. o Groshong-Manufacturer recommends 5 mls of normal saline only-and flush weekly when not in use. Note: Valved CVAD’s may require heparin when used long-term o Flush/Lock CVAD at least once a day when not in use.
  • 39.  Certain needless connectors contain devices that prevent the backflow of blood and hence eliminate the need for heparin.  Heparin should be avoided in patients who are allergic, have clotting disorders, have a history or develop thrombocytopenia.  When a 0.9% Sodium chloride solution is incompatible with a medication being administered, a 5% Dextrose in water flush should be used before and after, followed by a 0.9% sodium chloride flush, and then heparin lock if indicated. o Dextrose solution should always be flushed from the catheter because it can provide nutrients for biofilm growth.  Pediatric guidelines for flushing may vary and should be followed per MD order agency protocol.
  • 40. Device Intermittent Parentera Blood Blood Draws Flushing with No Heparin Locking l Product Therapy Nutrition Administratio n PIV Min 2 ml NA Preadmin 2 NA At least q 12 hours NA ml Postadmin 10 ml Midline Min 3 ml NA Preadmin 3 NA At least q 12 hours 3 ml 10 units/ ml heparin ml Postadmin 10 ml PICC Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least q 5 ml 10 units/ ml heparin ml Postdraw 10 24 hours Postadmin 10 ml Valved – at least ml weekly Non- Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least q 5 ml 10 units/ ml heparin Tunnell ml Postdraw 10 24 hours ed Postadmin 10 ml Valved – at least ml weekly Tunnell Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Nonvalved – at least 1- 5 ml 10 units/ ml heparin ed ml Postdraw 10 2 times per week Postadmin 10 ml Valved – at least ml weekly Port Min 5 ml 5 ml Preadmin 5 Predraw 5 ml Accessed Nonvalved – 3-5 ml 10 units/ ml heparin Reference: INS Guidelines T able for flushing ml Postdraw 10 at least 1-2 time per
  • 41. Device APV- approximate priming volume Locked Device: Volume, Frequency And Solution All saline should be preservative-free Medications: Pre- and Post- Administration Administration system/ methods include: large volume pump, gravity set, syringe pump method, and IV push. The unique tubing configurations used in this population and volume contained prohibit standardization of flush volumes. Blood Product Administration and Sampling Withdrawal Volume for Blood Sampling Accuracy Peripheral IV APV 0.05-0.07 ml NICU Patients: 1 ml NS every 6 hours Pediatrics: 1-3 ml NS every 8 hours 2 times administration tubing and add- on set volume Pre- and post-blood administration: 1-3 ml NS NA for routine sampling: for short-term studies follow locked device protocol, discard 1.5 ml for short-term studies from PIV dedicated to sampling Short peripheral Arterial APV 0.05-0.07 ml NA NA for medication administration Pre- and post-blood administration: NA Withdrawal volume for sampling: Stopcock Method: 1.6 ml Closed blood sampling system: refer to manufacturer recommendations Post Sampling: up to 1 ml NS or heparinized saline solution in 24-guage catheters and until clear for all other catheters Umbilical Catheter APV each lumen 0.15- 0.32 ml Umbilical Venous Catheter (UVC): Umbilical Arterial Catheter (UAC): typically not locked 1 ml saline solution or heparinized saline solution with <1 unit/ml heparin, or 2 times administration tubing and add-on set volume Pre- and post-blood administration: 1 ml NS or 1 ml NS + <1 unit/ml heparin and until clear Withdrawal volume for sampling when using a stopcock on catheter hub: 1.6 ml Closed blood-sampling system: refer to manufacturer recommendations Midline APVs [mls] 3 F-0.16 4 F-0.19 2F: 1 ml NS + 10 units/ml heparin every 6 hours 2.6F and larger: 2-3 ml NS + 10 units/ml 2 times administration tubing and add- on set volume Pre- and post-blood administration: 1-3 ml NS followed by locking solution or resume infusion. NA for routine sampling: for short-term studies follow locked device protocol, discard 1.5 ml for short-term studies from midline dedicated to sampling 5 F-0.22 heparin every 12 hours
  • 42. Device APV- approximate priming volume Locked Device: Volume, Frequency And Solution Medications: Pre- and Post- Administration Blood Product Administration and Sampling Withdrawal Volume for Blood Sampling Accuracy PICC APVs 1.9 F.: 0.06 ml 3-3.5 F: 0.2-0.5ml 4 F: 0.06 ml 5 F: 0.4-0.8 ml 6 F: 0.5-0.6 ml 2F: 1 ml NS + 10 units/ ml heparin every 6 hours 2.6 F and larger: 2-3 ml NS + 10 units/ml heparin every 12 hours 2 times administration tubing and add- on set volume 2 F Sampling and pre- and post-blood administration: 1 ml to clear the catheter, then flush with 1ml NS followed by locking solution until clear 2.6 F and larger sampling and pre- and post-blood administration: 1-3 ml NS followed by locking solution or resume infusion Withdrawal volume: 3 times administration tubing and add-on set volume Tunneled and Non-Tunneled APVs: 2-3 F 0.12-0.15 ml 4 F 0.3 ml 5 F 0.5 ml 6 F 0.6-0.8 ml 7 F 0.6-0.9 ml 9 F 0.6-1.3 ml NICU Patients: 1- 3 ml NS + 10 units/ ml heparin ever 12-24 hours Pediatrics: 2 ml NS + 10 units/ ml heparin every 24 hours 2 times administration tubing and add- on set volume Pre- and post-blood administration: 1 ml for NICU patients and 3 ml for all others of NS followed by locking solution or resume infusion Withdrawal volume for sampling: 3 times administration tubing and add-on set volume. Variation in size makes it difficult to recommend one volume for all patients. Ports APVs If used for more than 1 medication daily: 3-5 ml NS + 10 units/ml heparin Monthly maintenance flush: 3-5 ml NS + 100 units/ ml l heparin le for flushing ines Tab 2 times administration tubing and add- Pre- and post-blood administration: 3-5 ml NS followed by [mls] on set volume locking solution or resume infusion. 0.8 mm I.D.: 0.8 Withdrawal volume for sampling : 3 times administration 1.0 mm I.D.: 1.1- tubing and add-on set volume. Variation in size makes it difficult 1.2 to recommend one volume for all patients. 1.1 mm I.D.: 1.2 1.4 mm I.D.: 1.7 1.6 mm I.D.: 2 Reference: INS Guide
  • 43. Reference: INS Guidelines Table for flushing NACL Dextrose Heparin Heparin, Cont. GENERIC BRAND GENERIC BRAND GENERIC BRAND GENERIC BRAND Aldesleukin Proleukin ® Baclofen Lioresal® Alteplase Activase® GentamicinSlulfate Amphotericin B CholesterylSulfate Amphotec® Bupivicaine Marcaine® Amikacin Haloperidol Decancate Haldol Decanoate® Amphotericin B Deoxychoate Fungizone® Cladribine Leustatin® Amobertibal Sodium Amytal® Haloperidol Lactate Haldol® Amphotericin B Lipid Complex Abelcet® Clonidine Duraclon® Amphotericin B Cholesteryl Sulfate Amphotec® Hyaluronidase Hydase® Amphotericin B Liposomal AmBiosome® Dantrolene Dantrium® Amphotericin B Deoxychoate Fungizone® Hydrocortisone Sodium Phospate Solu-CorteF® Dantrolene Sodium Dantrium® Daptomycin Cubicin® Atropine Hydroxyizine HCl Daunerubicin Lipsomal DaunoXme® Dihydroergotamine DHE-45® Cefmatazole Idarubicin Dihydroergotamine Mesylate DHE-45® Interferon alpha 2 Intron®A Chlordiazepoxide Librium® Kanamycin Sulfate Epoetin Alfa Procrit®,Epogen® Intraconazole Sporanox® Ciprofloxacin Cipro® Levofloxacin Levaquin® Filgrastim Neupogen® Levothyroxine Sodium Synthroid® Clarithromycin Biaxin® Levorphanol Tartrate Levo-Dromoran® Immune Globulin Bammunex® Methadone HCl Dolophine® Codeine Methylprednisolone Solu-Medrol® Liposomal Doxorubicin Doxil® Phenytain Dilantin® Cytarabine Tarabine® Mitoxantrene HCl Novantrone® Methoxamine Vasexyl® Streptomycin Streptomycin Daunorbucin Hcl Cerubidine® Morphine Sulfate Mycophenolate Mofetil HCl CellCapt® Tenecteplase TNKase® Diazepam Valium® Nesiritide Natrecor® Nitroprusside Nitropress® TreprostinilSodium Remodulin® Dexorubicin HCl Adriamycin® Norepinephrine Bitartrate Levophed® Norepinephrine Levophen® Doxycycline Hyclate Orphenadrine Citrate Oxaliplatin Eloxatin® Droperidol Inapsine® Pentamidine Propafenone Rythmol Dretrecoginalfa Xigris® Phenytoin Sodium Dilantin® Propofol Diprivan® ErgonovineMaleate Methergine® Polymyxin B Sulfate Quinupristin/ Dalfopristin Synercid® ErythromycinLacte Prochlorperazine Edisylate Compazine® TrimetrexateGlucuronate Neutrexin® Filgrastim Nuepogen® PromethazineHCl Phenergan® Quinupristin/ Dalfoprisitin Synercid®
  • 44. Reference: INS Guidelines Table for flushing
  • 45.  INS and NHIA recommendations for lab draws for the adult patient are as follows: o Stop all infusions prior to blood sampling and flush the VAD with 10- 20mls preservative free 0.9% sodium chloride. o Discard the first 5mls blood drawn unless using for blood culture. o Remove cap/needleless connector before obtaining blood sample for culture, and include all blood drawn in the specimen. (no discard) o Flush with 10-20mls normal saline immediately following any lab draw, followed by lock solution if CVAD will not be in use. o For multi-lumen CVADs the sample should be drawn from the distal most lumen; (or lumen recommended by manufacturer) for drug level sampling, use the lumen not being used for the drug infusion. o Only the volume of blood needed for accurate testing should be obtained.  Pediatric guidelines vary between institution and agency and should be followed as such.
  • 46.  Hand hygiene is the #1 prevention in health associated infections (HAI). CDC guidelines for hand hygiene should be followed to decontaminate hands prior to contact with any aspect of the CVAD.  Recommendations from CDC and INS are for CVAD dressing changes 24-48 hours after insertion then a minimum of every seven days or when becomes wet, soiled, or loses it’s integrity.  If a gauze dressing is being utilized, all edges should be secured with tape.  The recommendation for a gauze dressing is to change it every 2 days.  Sterile gloves and face mask should always be worn when performing CVAD dressing site care.  Chlorhexedine solution, except in infants under 2 months of age, is the preferred skin antisepsis for VAD site care though a combination of 1- 2% tincture of iodine, povidone iodine and/or 70% alcohol may be used.  Apply all antiseptics to the skin with friction (scrubbing motion) to penetrate epidermal layers, even if applying in a circular motion from exit site outward. When alcohol/povidone combination is being used, alcohol scrub should precede the povidone scrub.  Allow all antiseptics (and skin protectants if used) to dry completely and naturally before applying dressing.
  • 47.  Caregivers may or may not be instructed in actual dressing change procedure, as it varies within organizational policy.  CVADS should not have any antibiotic ointments applied to insertion site due to potential for promoting infection and antimicrobial resistance.  Hub antisepsis is an important step in preventing microorganisms being transferred into the catheter lumen. o A 15-second scrub using friction with alcohol or chlorhexidine/alcohol to the needless connector/hub has been shown to prohibit microorganism entry on the surface. o It must be performed prior to every access of the catheter. For example, if using the SASH procedure to flush the CVAD this means 4 alcohol pads, one before each of the four steps in the procedure and allowing alcohol to dry prior to
  • 48.  As with any vascular access device, there are risks and complications associated with placement.  Air embolism: Air bubbles may enter the bloodstream during insertion, while in place, or upon removal. o Healthcare professionals, patients and caregivers must be educated in the prevention and signs and symptoms including: • tachycardia • lightheadedness • anxiety • confusion • palpitations • difficulty breathing • coughing • hypotension o EMS must be activated immediately and patient should be instructed to lie down on left side with feet elevated until emergency personnel arrive.
  • 49.  Phlebitis: Inflammation of the internal aspect of the vein. Symptoms include: • redness • pain at access site • streak formation • palpable venous cord o Nurse or physician must be notified so measures can be taken.  The three main causes of phlebitis are namely, mechanical, chemical and infective or bacterial phlebitis. o Mechanical phlebitis can occur during insertion or from repeated manipulation of the device. • Adequate securement of the catheter and use of warm heat can reduce the friction and inflammation; however signs and symptoms that persists may need further intervention. o Chemical phlebitis occurs when irritating drugs or solutions are administered through the catheter damaging the vessel. • Alternate VAD device may need inserted depending on therapy. o Infective phlebitis is caused from bacteria. • A localized infection may be treated with frequent dressing changes and antibiotics however a positive bacterial culture from the catheter or exit site may warrant removal.
  • 50. Grade Clinical Criteria 0 No Clinical Symptoms 1 Erythema at access site with or without pain 2 Pain at access site with erythema and/ or edema 3 Pain at access site with erythema , streak formation, and/ or palpable venous cord 4 Pain at access site with erythema , streak formation, palpable venous cord >1 inch in length, and /or purulent drainage Phlebitis Scale Reference: Box 23-5 Infiltration Scale. Page 472 Infusion Nurses Book.
  • 51.  Infection: May develop either inside the vessel or at the insertion site. o Site should be inspected daily for any redness, pain, swelling, pus-like drainage or fever and chills and should contact the nurse or MD immediately if develops. o Typically the source is directly related to the dressing covering the site and often due to a dressing becoming wet. o Once wet, moisture and body heat become an ideal breeding ground for bacteria. o Patients/caregivers must be educated to report wet, soiled or compromised dressings.
  • 52.  Occlusion: A catheter that becomes sluggish and difficult to flush, or unable to flush could indicate a partial or total occlusion. o Intraluminal occlusions occur as a result of blood clot formation within the catheter, medication incompatibilities or precipitates. o Extraluminal occlusions result from formation of distal fibrin sheath, catheter malposition, or mechanical obstruction (kinking). o Factors that predispose a catheter to occlusion are multiple infusion therapies, frequent blood sampling and improper flushing. o The patient/caregiver should be instructed to contact the nurse or physician for troubleshooting or early intervention. o Catheter should be assessed appropriately, and managed accordingly. o Use of an anti-thrombolytic agent may be indicated to prevent disruption of therapy and prevent further complications. • Anti-thrombolytic agents such as Cathflo can be used in midlines and CVADs when
  • 53.  Migration/dislodgement and damage: This occurs most often due to improper anchoring of device or excessive pressure when flushing the CVAD. o Any signs or symptoms of leaking at catheter site, wet dressing, swelling, burning, or pain in the arm, shoulder or neck should be reported. o Patient should be instructed to stop using the catheter and, if there is a visible crack or leak, apply a clamp above the site close to the catheters exit site, if possible. o Catheter repair kits are available but not routinely available for home use due to the many different manufacturers and types of CVADs. o Notify nurse/physician immediately.
  • 54.  Although the home care nurse provides expert clinical assessment, judgment and care to the CVAD, the patients and caregivers are ultimately responsible for the day to day care of the CVAD.  Patient education becomes a critical intervention in safe and reliable home infusion therapy and CVAD care.  Many factors, physically and mentally, affecting patients or caregivers ability and readiness to learn must be assessed and routinely evaluated.  Aseptic technique and hand hygiene should be repeatedly reinforced, demonstrated and observed.  Patients and caregivers should be taught to inspect the site and dressing daily for any irregularities and given clear and simple instructions about what and when report.
  • 55. 1. INS: Infusion Nursing Standards of Practice. Nursing Journal of Infusion 2011; 34, (1S) S37-S68 2. Hadaway, L. INS: Journal of Infusion Nursing: Short Peripheral Intravenous catheters and Infections 2012; 35(4) 230-235. 3. Carlos do Rego Furtado, L. INS: Journal of Infusion Nursing. Maintenance of Peripheral Venous Access and Its Impact on the Development of Phlebitis 2011;34 (6) 382-389 4. Dychter, S, Gold, D, Carson, D, Haller, M. INS: Journal of Infusion Nursing. Intravenous Therapy 2012; 35 (2) 84-91 5. Perucca, R. INS: Infusion Nursing, an Evidence Based Approach: Peripheral Venous Access Devices: Chapter 23 pp 456-479 6. NHIA: Central vascular guidelines for the Adult home based patient 6/25/11 7. INS: Policies and Procedures for Infusion Nursing 3rd edition. 84-102, 124-132 8. Lyons, M, Phalen, A. NHIA Infusion. An Evidentiary Review of Flushing Protocols in Home Care Patients with Peripherally Inserted Central Catheters 2012; 18(5) 32-40 9. Kramer, N Leone, M, Ross, K, Shaps, F, Cain, D. NHIA Infusion. CVAD Guidelines for Home Infusion. 2011; 17 (4)29-36 10. Hadaway, L. Targeting Therapy with CVAD: Nursing: 2008; 38(6) 35-40 11. Hufcut, T. Choosing an Effective and safe Central Venous catheter. An Evidence based Approach. Picclinenursing.com 12. Seigel, M. Kraemer-Cain, J. PICC Line Care at Home. Advance for Nurses. Nursing.advanceweb.com 13. Funaki, B. AJR Review. Central Venous Access: A Primer for the Diagnostic Radiologist. 2002; 179 (2) 14. Gorski, L. Home Healthcare Nurse. Central Venous Access Device Associated Infections: Recommendations for Best Practice in Home Infusion Therapy. 2010; 28(4) 221-229 15. CDC: Healthcare Associated Infections.(HAIs) Basic infection Control and Prevention Plan for Outpatient Oncology Settings 16. Bullock-Corkhill, M. INS: Infusion Nursing, an Evidence Based Approach: Central Venous Access Devices: Access and Insertion Approach, Chapter 24: 480-493 17.http://nursinglink.monster.com/training/articles/302-the-use-and-maintenance-of-implanted-port-vascular-access-devices www.journalofinfusionnursing.com 18.http://infonet2.upmc.com/OurOrganization/Enterprise/Quality/Infection/Pages/Central-Line-Toolkit.aspx