1. Principles and Management
Intravenous Lines 1

2. Aims To discuss Peripheral Venous Lines Planning
Indications
Complications
Planning
Good Clinical Practice 2

3. Aims (Cont) Central Venous Lines Golden Rules in IV Therapy Summary
Indications
Catheter choice
Types
Complications of insertion
Problems
Golden Rules in IV Therapy
Summary 3

4. Peripheral Venous Lines
80% of Hospitalised patients receive Intravenous therapy at some point during their admission.
Peripheral venous cannulation is the commonest method used for IV therapy
They are not devoid of complications leading to increased mortality and morbidity, increased hospital stay and significant costs 4

5. Indications for Peripheral Venous Lines
Intravenous fluid administration
Correction of electrolyte imbalance
Administration of blood and blood products
Drug administration
Prophylactic before procedures/surgery
Prophylactic in unstable patients 5

6. Complications Local: > Position /site 44% > Phlebitis 44%
> Infiltration and Extravasation %
> IV running too slow %
> Patient interference %
> IV running too fast % 6

7. Complications Systemic: Circulatory overload Pharmaceutical problems
Embolism
Allergic reactions 7

8. Planning
Is the key to ensuring this procedure is safe and effective for the patient.
3 distinct areas to consider:
> The Patient
> The Equipment
> The Environment 8

9. Good Clinical Practice
Obtain informed verbal consent
Explain the procedure to the patient
Patient allergies
ANTT to reduce the risk of local and systemic infections
Care of lines* (RCN 2010)
Know national and local guidelines/policies
Discuss when to change lines, labelling etc 9 9

10. Good Clinical Practice
Use of appropriate cleansing agent – Clinelle wipes for hubs/access ports (Chloroprep for skin cleansing)
Regular monitoring of vital signs
VIP score
Regular monitoring of access device insertion site
Duration of access device use
Removal of access devices
Documentation
Discuss re VIP scoring for cannula – not currently on meditech but being considered. At present just an IV page with insertion date, checks and removal.
Care of lines – if line disconnected then must not be reconnected, labelling giving set, duration of use dependent etc
Peripheral lines – 72hrs ( unless difficult to access then will need to use clinical judgement)
Documentation on meditech but also discuss re Fluid Balance Charts.
Policies on Grapevine 10

11. 11

12. Central Venous Lines
A CVC is an indwelling catheter threaded into the central venous circulation; the tip will always be in either:
- Superior Vena Cava
- Right Atrium
- Inferior Vena Cava (femoral approach) 12 12

13. Indications for Central Venous Lines
Administration of irritant drugs/solutions
and nutrition.
Monitoring of CVP in acute situations
Monitoring of Cardiac output
Obtaining venous access when peripheral route fails or long term access 13

14. Catheter choice
The type of central line used will depend upon the reason for insertion and the length of time the line is likely to stay in situ.
Preferable to use catheters with the minimum number of lumens
Use catheters impregnated with antimicrobials (with caution)
Ultrasound guided positioning (NICE 2002) 14

15. Types of Central Venous Catheters
Short-term Venous Catheters
Peripherally Inserted Central Catheters
(PICC)
Tunnelled Catheters
Implanted Venous Access Ports
Short term – 1-12wks
PICC – up to 12 months
Tunnelled – up to 3yrs but often replaced earlier due to problems with catheters blocking etc
Implanted (or portacaths) – accesses 15 15

16. PICC Line 16

17. Tunnelled catheter 17

18. Implanted venous access ports Port-A-cath18

19. Complications of insertion
Incorrect positioning of catheter
Haematoma
Haemorrhage
Arterial puncture
Pneumothorax*
Cardiac arrythmias
Pneumothorax – trauma to pleura on insertion – reinforce importance CXR on insertion to confirm postion. Pt can have slow pleural leak post insertion – discuss close observation post procedure in case any dyspnoea 19 19

20. Complications Perforation (R. atrium, Pulmonary artery)
Local and systemic sepsis:
Colonised catheter
Exit site infection/Tunnel infection
Catheter related blood stream infection can be serious with substantial and directly attributable mortality/morbidity (10-35%)
Discuss re statlocks/suturing lines in. Pros and cons.
Discuss local policies re sending catheter tips for m,c & s post removal – routine or only if indicated.
Discuss Biopatch dressings – BIOPATCH™ dressing with chlorhexidine gluconate is intended for use as a hydrophilic wound dressing that is used to absorb exudate The foam material absorbs up to eight times its own weight in fluid, while the CHG incorporated into the dressing inhibits bacterial growth under the dressing and to cover a wound caused by the use of vascular and non-vascular percutaneous medical devices such as: IV catheters, central venous lines, dialysis catheters, peripherally inserted coronary catheters, long term chest tubes, externally placed orthopaedic pins, and epidural catheters. Proven to reduce the risk of Major CRIs by 61%, and CRBSIs by 76%. 20 20

21. Complications (cont) Damaged catheter Catheter related thrombosis
SVC syndrome (Clot occlusion of blood flow in SVC)
Pinch off syndrome (rib compression of catheter)
Air emboli
Removal of catheter
Catheter related thrombosis – reinforce importance of correct size and flushing technique – push/pause 5 mls n/saline.
SVC syndrome – compression by outside structures, clot leading to increased pressure in veins to face leading to oedema (commonly caused by lesion but may be caused by clot)
Pinch off syndrome – catheter compressed between 1st rib and clavicle leading to occlusion.
Discuss re safe removal of central venous lines 21 21

22. Golden Rules of IV therapy
Plan as much as possible
Know national/local guidelines/policies
Know how to care for venous access device and how to remove safely.
Know how to use the equipment
Know how to prepare drugs/solutions
Know the risks/complications
Obtain verbal informed consent whenever possible
Know risks and complications of access devices as well as equipment, drugs etc 22 22

23. Golden rules of IV therapy
Use ANTT
Avoid unnecessary manipulation of lines/giving sets/pumps
Label lines, sites clearly
Regularly examine infusions while they are running
Monitor patients’ vital signs
Maintain good documentation
Know when to seek help and from whom
Reinforce re Grapevine access to BNF, Injectable medicines etc
Documenting infusion checks and insertion site checks
Reinforce not trusting infusion pumps 23 23

24. Any Questions ? 24

25. Summary Have discussed Peripheral Venous Lines & specific care
Planning
Good Clinical Practice
Central Venous Lines & specific care
Golden Rules in IV Therapy 25

26. References www.cs.cmu.edu/~pausch/news/PICCline.jpg
NICE (2002) Guidance on the use of ultrasound locating devices for placing central venous catheters Guidance No 49
RCN (2010) Standards for infusion therapy. The RCN IV Therapy Forum 3rd ed. 26