Presentation on theme: "Vascular Access at MUSC"— Presentation transcript:
1 Vascular Access at MUSC Lynn Williams, RNVascular Access Resource NurseSpecialty Nursing Department
2 Vascular Access Devices 2013 Objectives:Intro to Infusion Nursing Society (INS)Identify common types of venous access devices, inc general characteristicsDiscuss device selection & placement departmentsReview assessment, care and management of central venous access devices – C75 Central Venous Catheter PolicyIdentify potential complications and related interventions regarding a central venous access device
3 Infusion Nursing Society (INS) Recognized as the global authority in infusion nursing, dedicated to exceeding the public’s expectations of excellence by setting the standard for infusion care.The Standards of Practice are written to be applicable in all patient settings & address all patient populations.Be advised – the “Standards” is a legally recognized document.
4 General Characteristics of CVAD Catheter MaterialsPolyurethane, Silicone, Impregnated, FDA approved for Power injection of IV contrast during radiological imagingFrench Sizes1.2 fr – 15 frLumensSingle, double, triple, & quad available*Golden rule – Less is more!Cuffed vs non-cuffedValvesInternal (tip) – GroshongExternal (hub) – PASV, Solo Power PICCWith so many new products on the market it has become increasingly difficult for clinicians to keep abreast the nuances of each device. However, it is important that clinicians are knowledgeable re: the device design, purpose, limitations, warnings and precautions.Knowing what material the catheter is made of is important. Some catheter materials such as polyurethane are more thrombogenic than for ex. silicone. Patients at high risk for infection may benefit from those that are impregnated with antibiotic s ( Rifampin & Minocycline) or Silver.Catheters come in a variety of gauge sizes - from as small as 1.2 fr for the premature infant to 8 fr . – however, it is recommended to use the smallest gauge size to accommodate the prescribed therapy to reduce incidence of vein thrombosis.Catheters are available in single, double, triple and even quadruple lumens – however, studies show a direct correlation between number of lumens and risk of infection.Valves are built into the tip or external hub of catheters to prevent reflux of blood into the catheter to reduce catheter occlusion and use of heparin . Certainly, pts allergic to heparin could benefit from these catheters.44
5 Choosing the Best VAD for Each Patient DiagnosisPrescribed therapyDuration of therapyPhysical assessmentPatient health historySupport system/resourcesCase ManagersPatient preference55
6 List of drugs that d/t pH, osmolality or chemical structure, cause frequent IV restarts Amphotericin-irritantAll Penicillins – pH 10/hypertonicBactrim - pH 10.0Phenergan – pH 4.0Calcium Gluconate – HypertonicPotassium >20 KCL – HypertonicChemo Vesicants- pHPPN/TPN – HypertonicCiprofloxacin – pH 3.3Rocephin – Irritant/hypertonicDilantin – pH 12.0Dobutamine – pH 2.5Tobramycin – pH 3.0Erthromycin – irritantVancomycin – pH 2.4Morphine(PCA) – pH 2.5
8 CDC Recommendations Catheters & Site selection PIV vs PICC: Use a peripherally inserted central catheter (PICC) when the duration of IV Therapy will likely exceed six daysWeigh the risks/benefits of placing a central venous device (CVD) at a recommended site to reduce infectious vs mechanical complications (IJ vs Subcl vs femoral)
9 Catheter & Site Selection cont’d Choose a device with the minimum # of lumens/chambers essential for treatmentPromptly remove catheters that are no longer essential
10 Central Venous Access Devices Peripherally Inserted Central Catheters (PICC)Regular & cuffed/tunneledNon-tunneled/Non-cuffed Central CathetersTunneled/Cuffed Central CathetersImplanted Ports – regular vs powerThere are four categories of central lines – each will be covered separately.1010
11 Departments that Place &/or Manage CVAD’s VAIN TeamBedside PICC & difficult PIV insertionScreen all Adult IP PICC ordersAdultsInterventional Radiology Dept.Place all types of venous access devicesAll agesInfectious Disease PICC ServicePlace both cuffed & regular PICCsBronch Lab, EP, Cath LabOR/SurgeonsAll devices EXCEPT PICCsPediatric ServicesProcedural area on 5th floor of CH – PICCsBedside PICCs by specialized RNs in ICUs
13 Peripherally Inserted Central Catheters PICCs Usually inserted using a vein in upper armCan be used for most IV therapies and to obtain blood drawsSelect for pt’s requiring IV abx’s, TPN, poor IV access needing frequent blood drawsEasily removed either at bedside while an IP or by a Home Health Nurse after dischargeFYI – if pt has no insurance, they are unable to have device cared for at home
14 Adult PICC White BoardAll Adult PICC orders go to the VAIN team for evaluation and dept assignment for device insertionWhite Board provides info r/t which dept is assigned to insert PICC w/ commentsCertain criteria dictate which dept is best suited to place the PICC: occlusion history, sedation, complicated diagnosis
17 PICCs Placed at MUSC Cook Spectrum (polyurethane, Abx impregnated) BARD Power PICC(polyurethane)Cook SilasticPICCsCook Spectrum(polyurethane,Abx impregnated)
18 Centrally Inserted Catheter Non-Tunneled CVC (no cuff)Short term, Acute care, percutaneous cathetersTypically used for days – weeks for all types of IV therapy, blood draws, monitor central venous pressure in ICUsExample: PICCs, Acute single/dual/triple/Quad CVCs, Dialysis/aPheresis cathetersTunneled CVC (cuffed)Long term therapies – TPN, chemoOncology, Cardiac, GI patientsDacron cuff provides catheter stability and serves as a barrier to prevent infectionExamples: Cuffed PICCs, Chronic Dialysis/aPheresis catheters, Hickman, Broviac,Non-Tunneled catheters are temporary, short term catheters inserted percutaneously into the subclavian, jugular, and femoral veins. They can be inserted in an emergency situation at the bedside or in IR. Often, used if there are contraindications to using the veins of the upper arm for PICC insertion. Can easily be exchanged over a guidewire if infection is suspected or if multiple lumens no longer required.Tunneled catheters are surgically placed by tunneling the catheter under the skin from the vein entry point to an exit point on the chest. A nylon or Dacron cuff encircling the catheter provides catheter stabilization and serves as a barrier to infection as the tissue in the tract grows onto the cuff. These catheters are used when patients will require long-term therapy infusion.1818
19 Tunneled Non-tunneled IJ entry siteIJ entry siteSubcutaneousTunnel w/cuffNo subcutaneousTunnel or cuff
21 Implantable Ports Chest, Arm, Thigh, Abdomen Implanted Ports- Plastic, stainless steel or titanium housing attached to a catheter implanted under the skinChest, Arm, Thigh, AbdomenCompletely under skin – swimming permitted when not accessed once the incision has totally healedRequires special non-coring needles to accessAvailable as power injectableCan remain in place for yearsSickle cell, Oncology, Rheumatoid Arthritis, intermittent long term tx’sSubcutaneous implanted ports consist of a reservoir made of plastic, titanium or stainless steel with a self-sealing slicone septum attached to a radiopaque catheter. The catheter is tunneled but instead of exiting the chest it is attached to the reservoir and placed in a surgically created SQ pocket.Accessed with a Huber non-coring right angle needle – the smallest gauge size needle to accommodate the infusion should be used to prolong the life of the port. Nurses must assess which needle length is a perfect fit for the individual patient. May change as swelling goes down post insertion and with weight loss. If it is too short or too long the needle can back out of the silicone and infiltrate the infusion under the skin. Important to get swelling down and flush port before it clogs!Topical anesthetic creams can be used to minimize patient discomfort. – most pts request to be left on for 1 hour.Reminder, most pre-filled syringes are not sterile on the outside and should not be dropped on the sterile field when priming the huber needle.To meet the needs of patients requiring CT scans with contrast, ports have been developed to withstand the high pressures of power injectors, identified by ridges on the surface of the port or radiographic markings. When using power injectors, special noncoring needles that have the tubing attached must be used to ensure that the tubing and connections will not rupture or separate.2121
22 Identifying Power Ports Prior to a fluoroscopic exam requiring power injection of contrast:Clinical staff (radiology techs, RNs) will positively ID deviceManufacturers ID card, arm bracelet, key tagManufacturers sticker found on IR/OR documentImage – view “CT” marker on port chamberRadiologist to review prior image before being usedIf no prior image, an image of the appropriate anatomic area will be done & reviewed by RadiologistRadiology Dept. has a process they follow to confirm if a device is power injectable.
25 Before Meds can be administered via CVAD: Verify tip location using fluoroscopyFor newly placed devicesTransferred patients with an indwelling central venous catheterIf there is a known or questionable change in catheter positionMigration or dislodgement suspectedSecurement device has become dislodgedS/S: No blood return &/or unable to flushIf no blood return, device is not to be used until evaluated/treated for clot/thrombus or mechanical issues!Extremely important to verify initial tip placement and assess whether the tip position may have changed before administering medications.Solutions or medications with a pH <5 or >9 predispose the vein intima to irritation. Some examples are Doxycycline Ph 1.8, Dopamine Ph 2.5, Levaquin Ph 3.0, Tobramycin 3.0, Cipro Ph 3.3, Potassium 4.0, Phenergen 4.0, Vanco 2.4 – 4.5, Bactrim 10, Acyclovir 11, DilantinTo put that into perspective, I like to compare the pH of medications to things such as Gastric acid pH 1.5 – 2.0, Vinegar pH 2.9, and on the other end of the spectrum Ammonia pH 11.5.Continuous chemotherapy should be given via central line to prevent possible infiltration.Both cytotoxic and noncytotoxic (such as Nafcillin) have the potential for being categorized as irritants and vesicants because of chemical nature – this may have nothing to do with pH or osmolality.The vein intima can also be traumatized by the administration of hyperosmolar solutions (an osmolality >600) such as TPN, IVIG preparations25
26 IV Flush Orders Practitioner must write order for heparin flushes Standard Adult and Pediatric flush ordersEach device has a standard flushing protocol including 0.9% sodium chloride and heparinIf heparin is contraindicated, consider alternative, such as argatroban or tPAWhen patient is admitted with a device, initiate the order for RN to get heparin
27 Dialysis/aPheresis catheters Locked with high-dose heparinRefer to IV Flush OrdersAdults: Use 1000u/ml heparinPediatrics: Use 100u/ml heparinMay only be accessed by nurses trained to do so (ICU, aPheresis & Dialysis RNs)Renal service must be consulted before using catheter. If no longer being used for aPheresis &/or dialysis, the Renal MD MUST transfer care to RNs on unit.
28 Post-Insertion Complications Catheter DislodgementCatheter MigrationAir EmbolismCatheter-related Bloodstream InfectionVenous ThrombosisCatheter OcclusionThe patient is at risk for a number of complications as long as the catheter remains in place . The nurse /pateint and/or caregiver must constantly monitor for sx’s and sx’s of complications, be proactive to prevent complications from occurring and be knowledgeable of which actions to take in the event of their occurrence.2828
29 Catheter Dislodgement Stabilization devices (Statlock, sutures, securement dressings) are used to prevent catheter from falling out, catheter tip malposition, and migration of bacteriaIf displacement is suspected, CXR is required to verify tip placementS/S of dislodgement – catheter malfunctioning, securement device lose, device is semi-pulled outDo not try to re-insert the deviceEven with stabilization devices or sutures, catheters can fall out, be pulled out or become dislodged.Nursing assessment should should include measurement of the length of the external part of the catheter at the time of placement as a baseline; tunneled catheters should be palpated to assess for coiling and exposure of the dacron cuff.Difficulty with apiration or infusion, leaking of solution from exit site, edema or burning sensation, or pain with infusion can also indicate a displaced catheter.CXR is required if catheter tip displacement is suspected2929
30 Catheter MigrationTip can spontaneously migrate into right atrium or internal jugularMay result from coughing, ventilator, forceful flushing, heavy lifting, hypertensionS/S = Inability to flush, infuse or aspirate“Ear gurgling” or “running stream” while catheter is being flushedGet a chest x-rayCatheter tip placement is always confirmed after insertion and before using to administer medications. However, the tip can spontaneously migrate into an adjacent vein resulting from changes in intrathoracic pressure associated with coughing or sneezing, mechanical ventilators, forceful flushing as with power injection, or heavy lifting.Some indicators that the tip may have migrated include: inability to flush, infuse or aspirate; ear gurgling or running stream heard when the catheter is flushed. Also, complaints of headache or pain, swelling, redness or discomfort in the shoulder, arm or neck may indicate catheter migration.If suspected, venographic studies should be performed. Infusing medications into these other areas can result in venous thrombosis. Generally, can be repositioned by guidewire exchange.3030
31 Catheter Tip Malposition right jugularThe picture shows a catheter tip that has migrated into the right jugular vein.31
32 Catheter Related Bloodstream Infections (CRBSI) During CVC insertion – use maximal sterile barrier precautions:Cap, mask, sterile gown, sterile gloves, sterile full body drapePut mask on if removing a dressing to inspect a sitePrep skin using Chlorhexidine gluconate w/ alcohol – allow to dry!!Assess catheter necessity daily!
33 Venous Thrombosis Diagnosed via Vascular Ultrasound What do you do?? Before removal, consider this:Is the catheter functioning normally?Are symptoms manageable?Can patient receive anticoagulant treatment?Does patient have known occluded vessels that will compromise a new device plcmt in the future?Consider patients condition, long term treatment and the need for the existing device
34 Occlusion ManagementPartial Occlusion: device flushes, no blood returnTotal Occlusion: No flush or aspiration via deviceBoth types of occlusions can safely be treated with Cathflo Activase (alteplase)If mechanical malfunction has been ruled out, order Cathflo for catheter occlusionFollow Occlusion Management guidelines (Appendix B in C75 Policy)
35 Device RemovalRNs have to demonstrate competency to remove a non-tunneled catheter.RN competency is based on skill & frequency of performanceONLY dialysis or ICU RNs w/ demonstrated competency may remove large bore catheters (dialysis/aphersis)ONLY MDs and non-surgical specialist that are credentialed may remove cuffed devices, including PICCs.
36 Air embolism = entry of a bolus of air into the vascular system; can occur during placement or after device removalReduce the risk of embolism:Place the patient in Trendelenberg position to increase intrathoracic pressure, unless not tolerated or contraindicatedHave patient hold breath and gently bear down (Valsalva).Sx’s & Sx’s include: palpitations, resp distress, hypotension, arrhythmias,
40 CDC RecommendationsEducate/training clinicians who insert/maintain cath’s – *SIM Lab program being developedUse maximal sterile barrier precautionsUse >0.5% chlorhexidine skin prep w/ alcohol (ChloraPrep = 2% = isopropyl alcohol)Avoid routine replcmt of CVCs as strategy to prevent infectionPeriodically assess knowledge of & adherence to guidelines
41 Central Venous Catheter Policy Owner: Central Venous Access CommitteeMultidisciplinary teamPurpose: Provide guidelines for the insertion & care of all VADsFor all staff that handle or insert a Central VADIncludes:8 Appendix Included: References, VAD Occlusion Mgmt, IV Flush Orders (Peds/Adults), CVL Guideline, Ethanol Lock Info Sheet, VAIN Team Guidelines