central venous devices

1. Central Venous Devices

2. 2 TYPES OF DEVICES
 PIV’s
Short catheters (less than 3
inches) placed in the veins
of the upper extremities.
 CVAD’s
Long catheters whose
terminal tip position is in
the central veins.

3. VENOUS ACCESS DEVICES
Peripheral
 Most appropriate
device for short term
therapies (less than 5
days) that are
nonirritating.
Central
 When ordered
medications have pH
greater than 9.0 or less
than 5.0, osmolality
greater than 500
mOsm.
 Ordered meds/fluids
are known irritants
 Preparation with
dextrose con-
centration greater than
10%.
 IV inotropes

4. Reasons For Inserting Central Venous
Catheters
 Limited vascular access
 Administration of highly osmotic or caustic fluids
or medications
 Frequent administration of blood and blood
products
 Frequent blood sampling
 Measurement of CVP
 Hemodialysis

5. Type of CVC Inserted Depends On
 Patient’s condition
 Anticipated length of therapy

6. Types Of Central Venous Catheters
 Nontunneled central catheters
 Tunneled central catheters
 Peripherally inserted central catheters (PICC)
 Implantable ports

7. NON-TUNNELED EXTERNAL CATHETERS
 1. Polyurethane
 2. Single or multiple lumens
 3. Flow varies depending on size and ID
 4. Temporary - requires frequent exchanges
 5. Easier placement, removal and replacement

9. Non tunneled Central Venous Catheters
 Used for short-term therapy
 Inserted percutaneously
 Subclavian vein
 Internal jugular vein
 Femoral vein
 Has from 1 to 4 lumens or ports
 Usually from 6 to 8 inches in length

10. Non tunneled Central Venous Catheters
 Can be quickly inserted
 Not flexible and may break
 Dislodged more easily
 Has the highest infection rate
 Dressing changes required using aseptic technique
 Unused ports must be routinely flushed with heparin
solution and clamped

11. TUNNELED CATHETERS
1. Single or multiple lumens
2. Flow - variable
3. Long term
4. Easy access (no skin puncture)
5. Tunnel provides stability
6. Protects against endovascular infection.

12. Tunneled catheter with cuffs

13. Tunneled catheter

14. Tunneled Central Venous Catheters
 Used for long term therapy
 Inserted surgically
 Small Dacron cuff sits in subcutaneous tunnel
 No dressing is required after cuff heals unless the patient is
immuno -compromised
 Initially sutured but removed in 7 to 10 days
 External portion of the cath can be repaired

17. Peripherally Inserted Central Catheters
(PICC)
 Used for intermediate to long term therapy
 May be single or double lumen
 Inserted percutaneously
 Basalic vein
 Cephalic vein
 Threaded into the superior vena cava
 May be inserted by specially trained RN

18. PICC LINES
1. Silastic or polyurethane
2. Single or double lumen
3. Low flow
4. Short - long term
5. Easy access

20.  Infusing or drawing blood from smaller gauged PICC
may be more difficult
 Small gauged PICC infuse fluids slower and occlude
faster
 Measure and document external length of PICC with
each dressing change
 Dressing acts as a bacterial shield and helps anchor
cath
 Unused ports must be flushed with Heparin solution
and clamped

21. SUBCUTANEOUS PORTS
 1. Single or double lumen
 2. Flow - most commonly slow
 3. Long term
 4. Access requires needle puncture

22. SUBCUTANEOUS PORTS
5. Less maintenance
6. Activity is unlimited after site heals
7. Cosmetically more appealing
8. Concealed pocket retards infection

23.  Minimizes infection
 Huber needle must be used to access port
 Must always confirm needle placement before med
administration
 Transparent dressing covers Huber needle and port
 Unused port is flushed every 28 days with Heparin
solution

25. SUBCLAVIAN VEIN COMPLICATIONS
STENOSIS THROMBOSIS PINCH OFF
SYNDROME
Subclavian vein (SCV) access is prone to more complications than internal jugular
vein (IJV)

26. ADVANTAGES OF THE RIGHT IJ
1. Larger
2. More superficial
3. Further from the lung
4. More direct route to the heart
5. Acute and chronic complications are reduced

27. Preparation
 Alcohol scrub to remove surface oils
 Chlorhexidine scrub
 Betadine prep (allow to dry)
 Ioban dressing and drapes
 Maximum Sterile Barrier - Surgical hats, gowns, masks & gloves
 3 - 5 min. surgical scrub
 Antibiotics (controversial) 30-60 min. prior
Cefazolin (Kefzol, Ancef) 1 gm IV or
Gentamycin 80 mg IV

28. General Nursing Care Of Patient With CVC
 Always follow the institution’s policy and procedure
 Before insertion, lines are initially flushed with saline
 During percutaneous insertion of CVC in the
subclavian or jugular, place patient in Trendlenberg or
have him perform Valsalva maneuver
 After insertion, an occlusive gauze or transparent
dressing is applied
 Blood is aspirated through all lumens to verify patency

29.  Chest X- ray must be performed before use
 Each lumen of the cath is secured with a Leur-lok cap
or CLC 2000 device
 Use only needless system to access ports
 Infusing devices are used for all infusions
 TPN is administered exclusively through a dedicated
line and port.

30.  Flushing of lines
 Each lumen is treated as a separate cath
 Injection caps are vigorously cleaned with alcohol
 Use 10cc or larger syringe for administration of meds
or flush
 Turbulent flush technique is recommended

31.  If port is not to be maintained with a continuous infusion,
end with Heparin flush solution
 Peds 10kg> and adults – 100 units Heparin/ml with
preservatives
 Neonates and peds <10kg – 10 units Heparin/ml without
preservatives
 For specific amounts see procedure
 Clamp cath while infusing last ½ cc of flush
 If CLC 2000 used, do not clamp cath until syringe
disconnected

32.  Site assessment and determination of external cath
length is performed and documented with each
dressing change
 Tunings are changed per protocol – 72hrs
 Caps and connections are changed per protocol – 3-7
days

33.  Dressing changes per protocol
 Use sterile technique
 Change when damp, soiled or loosened
 Change every 7 days if transparent
 Change every other day if gauze is used
 Clean skin around insertion site with alcohol in a
circular motion. Also clean cath with alcohol

34.  Use antmicrobial disk if indicated
 Form a loop of the tubing or cath outside the
dressing and anchor securely with tape
 Label site with date, time and initials
 Document dressing change, condition of site and
length of external cath when appropriate

35.  For drawing blood specimen
 Discard initial sample of blood
 Collect specimen
 Flush with 10cc saline
 Flush with Heparin solution if indicated

36.  Monitor for complications
 Infection
 Phlebitis
 Septicemia or pyrogenic reaction
 Air embolism
 Thrombosis/occlusion
 Extravasation
 Damaged cath

37. COMPLICATIONS
1. Acute Procedural
2. Sub-acute Infection
3. Chronic
 Infection
 Catheter fragmentation
 Non-function

38. COMPLICATIONS:
ACUTE
 1. Spasm 4. Pneumothorax
 2. Access failure 5. Malposition
 3. Arterial puncture 6. Air embolus

39. AIR EMBOLUS: SYMPTOMS
 1. Respiratory distress
 2. Increased heart rate
 3. pulse
 5. Cyanosis
 4. Poore in the level of consciousness

40. AIR EMBOLUS: TREATMENT
1. Left lateral decubitus (Durant’s) Position
2. 100% O2
3. Vasopressin if necessary
4. Chest compression
5. Aspiration through catheter +/-
Mortality decreases from 90% to 30%with conventional
treatment

41. COMPLICATIONS:
CHRONIC
1. Infection
2. Catheter fragmentation
3. Non-function

42. Risk Factors
 Four major risk factors are associated with
increased catheter-related infection rates:
 Cutaneous colonization of the insertion site
 Moisture under the dressing
 Prolonged catheter time
 Technique of care and placement of the central line

43. Evidence-Based Strategies Selected to
Reduce CLA-BSIs
1. Central line-associated bloodstream infections
bundle
2. Hand hygiene
3. Maximal sterile barriers
4. Chlorhexidine for skin asepsis
5. Avoid femoral lines
6. Avoid/remove unnecessary lines

44. Hand Hygiene
 Cornerstone of any infection
prevention program
 Many studies have shown that
improvement in hand hygiene
significantly decreases a variety of
infectious complications
 Insufficient or ineffective hand
hygiene contributes significantly to a
greater bacterial burden and
subsequent spread of microorganisms
within the environment

45. Hand Hygiene
 Use of waterless alcohol-base
hand rub
 Most effective and efficient
method for hand antisepsis
against bacterial pathogens
 When hands are visibly
soiled, they should be washed
with soap and water

46. Efficacy of Hand Hygiene
Preparations in Killing Bacteria
Good Better Best
Plain Soap Antimicrobial
soap
Alcohol-based
handrub

47. Maximal Sterile Barriers
 One study found a 6-fold
higher rate of catheter-
related septicemia when
minimal sterile barriers
(sterile gloves and small
drape) were used instead of
maximal sterile barriers
Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous
catheter-related infections by using maximal sterile barrier precautions
during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.

48. Chlorhexidine for Skin Asepsis
 Studies have compared chlorhexidine gluconate
(CHG) versus povidone iodine as a skin antiseptic
for catheter insertion and routine insertion site
care
 Recent meta-analysis, the use of CHG rather than
povidone iodine was found to reduce the risk of CLA-
BSIs by approximately 50% in hospitalized patients who
required short term catheterization
Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine
compared with povidone-iodine solution for vascular catheter-site care: a
meta-analysis. Ann Intern Med. 2002;136:792–801.

49. Benefits of CHG
 2% CHG in tincture of isopropyl alcohol has rapid
bactericidal activity and is effective within 30 seconds
after application versus 2-minute period for povidone
iodine
 CHG provides persistent bactericidal activity on the
skin and maintains its activity in the presence of
other organic material
 Minimal systemic absorption

50. Site Selection: Avoid Femoral Lines
 Insertion of CVCs can lead to serious and
sometimes life-threatening complications,
whether of mechanical, infectious, or thrombotic
origin
 Higher rate of infectious complications in study
comparing femoral lines versus subclavian lines
 19.8% vs 4.5%

51. Avoid and Remove Unnecessary Lines
 Once placed, there should be periodic, if not daily
assessment, of its continued need, with emphasis on
prompt removal

52. TYPES OF INFECTION
 EXIT SITE, TUNNEL/POCKET or CATHETER
1. Cutaneous - pain, erythema, swelling +/- exudate
2. Bacteremia - fever, leukocytosis and positive blood
cultures
3. Septic thrombophlebitis – bacteremia thrombosis
and purulent discharge

53. INFECTION : CAUSATIVE ORGANISMS
 Staph epidermidis 25-50%
 Staph aureus 25%
 Candida 5-10%

54. INFECTION
1. Septic thrombophlebitis - remove catheter
2. Cutaneous - local treatment
3. Bacteremia –
IV antibiotics 48 -72 hours if improved - keep catheter,if
no change, worse or recurs remove catheter or
Exchange catheter over wire,
 85% cure with treatment
 Continue to treat infection for 10 - 14 days
 If ineffective - try locking with thrombolytics between
antibiotic doses and administer antibiotics through
catheters

55. Discharge Teaching For The Patient With A
CVC
 Proper handwashing and principles of sterile
technique
 Dressing change procedure and frequency
 Flushing and cap change procedure and frequency
 Observation of cath and insertion site

56. When to call the physician
 Temp of 100.5F or greater
 Chills, dyspnea, dizziness
 Pain, redness, swelling, or drainage at site
 Unresolved resistance, pain or fluid leaking while
flushing
 Hole or tear in cath
 Excessive bleeding at site
 Change in length of external cath
 Swelling in neck, face, chest, or arm

57.  General safety measures
 No sharp objects near cath
 Clamp cath when not in use
 No pulling or tension on the cath
 Discard syringes and needles in sharps container
 Activity limitations
 Use a stress loop
 Home health referral

58. Discontinuing A CVC
 Follow the institution’s policy and procedure
 For percutaneous internal jugular or subclavian
insertion sites, place patient in trendlenburg position
and have him perform the Valsalva maneuver
 Remove cath and apply pressure with an occlusive
dressing over a petroleum gauze
 Check cath to ensure tip is intact
 Document how patient tolerated procedure,
placement of dressing and cath tip intact

59. Sources
 Molihan C, lockart C, patterson S, ryan M. Clinical policies,
procedures & guidelines. Central venous access device (cvad)
management guideline. August 2009.
 Adams S, Linda B et al. Central Venous Access Devices:
Principles for Nursing Practice and Education. 2007 Cancer
Nurses Society of Australia.