Introduction to CVADS CCN Nursing Education 2010

Objectives: Session participants will understand that: There are different types of venous access Ensuring adherence to policy and procedure is essential for safety of the patient There are multiple complications associated with CVADs Knowledge of the care for the different types is required prior to utilizing the lines

Central Venous Access Device Venous access device whose tip dwells in the distal one-third of the superior vena cava. Long term tunneled Short term non tunneled PICC line (peripherally Inserted Central Catheter) IVAD (Implanted Venous Access Device) We here many terms associated with central lines. We are encouraging the use of the term CVAD – Central Venouse access device. You will hear them called CVC, central lines, broviac, hickman, PICC, etc. When we discuss the CVAD, we are talking about all lines that have the tip in the central venous system, typically in the superior vena cava. These lines can be broken down into four main categories, which we will discuss each in detail later on.

CVAD Tip rests in a large central vein and is responsive to changes in thoracic pressure

Why Use a CVAD? Prescribed therapy Duration of Therapy Physical assessment Health history Support systems Patient preference Prescribed therapy: Consider the type of therapy the patient requires. Is there multiple infusions required at once, a very high amount of fluid. Is the fluid a vesicant? Some medications require good hemodilution. Fluids such as vesicants and TPN should be infused through a CVAD to avoid irritation to the vein. As well, a patient requiring multiple blood draws may benefit from a CVAD. Duration of Therapy: RNAO suggests that patients requiring infusions for more than 6 days should be assessed for a CVAD. This will decrease the amount of pokes and decrease the incidence of phlebitis. Physical assessment – does the patient have a chronic illness? Do they have poor, fragile veins? Lymphodema? Will mobility and activity level be impacted? Health history: Previous treatments, diagnosis (e.g., breast patient with mastectomy) can all affect the choice of access. Support systems – is the patient or family able to properly care for a CVAD while at home? Patient preference – allow the patient an opportunity to ask questions, and be involved in the planning. They ultimately have to be the ones with the line.

Long Term Tunneled Entrance site Superior Vena Cava Line tunneled under the skin Dacron Cuff Exit site LTT lines can stay in indefinitely as long as there are no complications. These are inserted through the skin on chest or abdomen. The catheter tip is placed in the vein via the insertion site near the clavicle and terminates in the distal 1/3 of the superior vena cava. Thereafter, a tunnel is made under the skin from the insertion site and the other end of the line is pulled through the tunnel to the exit site on the chest. The sutures over the entrance or insertion site must stay in place for 7 days. These lines are put in in the OR or in OI. The Dacron cuff on the LTT lines helps to prevent migration of bacteria, and assists in anchoring the line. Research has recently shown, however, that about 50% of Dacron cuffs fail. Past policy has been that due to the Dacron cuff, these lines were an aseptic dressing change. Due to the recent research, these will be treated as a sterile dressing change

PICC- Peripherally Inserted Central Catheter Inserted in antecubital region and threaded into central circulation Very soft and flexible, easily damaged Lower risk of infection No BP’s or venipuncture on that arm May be removed by RN once observed Single or double lumen May be an open or a closed system

Groshong Tip Special tip designed to keep line open No heparin required Pressure to infuse opens valve and allows fluid to enter Aspirating for blood opens valve inward to allow for withdrawal. WE use Groshong’s mainly here in the CCI, but do use other types as well. It is important to know what type of PICC line you are using.

Other PICCS Many different types: Some have valves in hub that do not require heparin Check for clamps, valved lines have no clamps Power PICCS Used for power injections for contrast with CT Open-ended PICCs Require heparin if not using positive pressure caps Look at your PICC to determine what type it is. Typically at the CCI, we use groshongs, but you may see a Vaxcell (closed ended), Cook (open ended), Purple power PICC, SOlO power PICC (Closed ended power PICC), or turbojet (Cook Power PICC). It is important to document your PICC by type, so as to ensure the proper maintenance of it. The staff currently are using heparin with the positive pressure caps. It is fine to continue with this practice.

You must have a CXR to confirm placement of all lines prior to use You must have a CXR to confirm placement of all lines prior to use. This shows a CXR of a PICC line inserted in the superior Vena Cava

Care of lines: Vigorously scrub hub Flush with 20 cc NS prior to and immediately after accessing for any use Weekly if not in use Following blood draws, an infusion of lipids, blood/blood products or medications known to crystallize or precipitate Ensure that positive displacement caps are on the lines (these are the ones we use here). If a patient does not have these caps, they require flushing with heparin post NS flush if not in use. If blood, TPN, or a crystallizing medication is used, flushing with 20 cc NS will help to clear the line. Always use a positive pulsing pressure for all venous access devices to help clear the line. Ensure you flush all lines before and after use, to clear the line. Always use positive pulsing pressure (start-stop technique) to ensure good turbulence created to clear the line.

Open Ended (Non-Valved) CVAD – Adults Flushing Guidelines Open Ended (Non-Valved) CVAD – Adults Device Frequency Solution and Strength Volume Implanted Ports Once a Month Heparin – 100 units/mL 5 mL Tunneled Q 7 days Heparin – 10 units/mL PICC 3 mL Closed Ended (Valved) CVAD We use positive pressure caps for all our lines. It is important to always use positive pulsing pressure to effectively clear the lines. We don’t require heparin when using the posiflow caps, but it is okay if you use it. These are the typical amounts and types of flushing with regular caps. Device Frequency Solution and Strength Volume Tunneled Q 7 days Normal Saline 10 mL PICC

Injection Cap Changes Injection caps are to be changed on all CVAD lumens in the following circumstances: Every 7 days and as needed in hospital Every 4 weeks and as needed in out patient settings depending on frequency of access of catheter If it is leaking or broken If blood is trapped in the injection cap If the cap is removed for any reason

Injection Cap Changes Vigorously clean the injection cap/catheter connection extending 1.5 cm above and below the injection cap/catheter connection using 70% isopropyl alcohol. Allow to dry completely Remove injection cap from catheter lumen using sterile gauze Clean outside threads of catheter hub only if visibly soiled, ensuring antiseptic does not enter the catheter lumen. Allow to dry Apply new sterile injection cap to lumen Flush and lock lumen following injection cap change If Line is open ended, ensure that it is clamped to prevent air from entering the line. This should be treated as a sterile procedure. Only clean the threads if they are soiled. More manipulation of the hubs increases the likelihood of a blood stream infection.

Dressing Changes: Gauze dressings used 24 hrs post-insertion If patient allergic or intolerant to transparent dressings If the catheter exit site inflamed, draining, or a site infection suspected Dressings should be changed: 24 hrs post insertion Transparent semi-permeable membrane dressings every 7 days and as needed Transparent over gauze every 48 hours and as needed Gauze dressing every 48 hours and as needed If the injection cap is to be changed as part of a CVAD dressing change, the injection cap should be changed prior to the dressing change. It is best to use the TSPM (Transparent semi-permeable membrane) or Opsite 3000 dressings. These provide better visualization of the insertion site to assess for infection.

Dressing Changes: Use sterile dressing tray Clean entire area of skin to be covered with dressing Use Chlorhexadine swabsticks Ensure entire area dry prior to placing dressing Securement devices are not needed for tunneled catheters Change caps prior to dressing changes Chlorhexadine can cause a reaction when it has not dried properly. The solution we use has some alcohol content, so it requires 30 seconds to dry. Do not blow on the line to dry it, if it is wet after 30 seconds, wait until it is completely dry. Securement devices are not needed with LTT lines. The Dacron cuff helps to anchor the line, and the dressing will help to secure it as well.

Stat locks for PICCS PICC securement device, used in place of sutures Change with each dressing change Remove old dressing and device with clean gloves

Removal of StatLock Lift edge of anchor pad using alcohol swabs alcohol will dissolve undersurface of pad away from skin. Stabilize catheter while holding the StatLock® device Use thumb of opposite hand to gently lift door from behind, while pressing down with index finger Lift PICC from holder, and place to the side

Adding new StatLock Using Sterile technique, cleanse entire site with Chlorhexadine Allow to dry completely Apply provided skin protestant to securement site Align anchor pad so directional arrow points towards insertion site Peel away paper backing from anchor pad, one side at a time, then place on skin Apply transparent dressing

Suture removal for tunneled catheter A physician/NP’s order is required to remove sutures. At the insertion site, 7 days post At the exit site/catheter skin junction, typically 10 to 14 days post tunneled CVAD insertion Tunneled catheters come with a suture on the exit and entrance site. A physician/NP’s order is required to remove sutures. They should be removed at the insertion site, 7 days post insertion, and at the exit site/catheter skin junction, typically 10 to 14 days post tunneled CVAD insertion. Physician orders are required to remove the sutures. If there is no order, leave them in. There have been a lot of issues with the removal of sutures at the exit site. Policy states to remove them at this interval, with a doctors order. There has been some evidence to recommend removing these sutures, as a biofilm of bacteria can form on the suture, and put the patient at risk for a bloodstream infection. This is still under investigation.

IVAD – Implanted Venous Access Device Left in place until treatment complete, or complications occur Located beneath the subcutaneous tissue Appears as a palpable protrusion under the skin Lower risk of infection May only be accessed with a non-coring needle Needles to be changed every 7 days or days if infusing TPN/blood products These are a soft catheter attached to a reservoir, which is covered by a self sealing septum. They are inserted in the OR. They may be placed in a subcutaneous tissue pocket the chest or upper abdomen, as well as occasionally in the arm. The catheter is threaded into a major vein.

IVADs IVAD’s can be single or double lumen. Ensure you palpate well to ensure which one you are dealing with. Double lumen IVAD’s must have both lumens flushed Q Monthly.

IVADs IVAD’s must only be accessed by a special non-coring needle (bevel on the side, which eliminates the potential to core a septum). These are often referred to as Huber or griper needles. There are different sizes (length) of these needles. The patient is usually the best resource as to the proper size. If unable to ask the patient, check to chart to determine the appropriate length. There is a reservoir underneath the septum, which holds a volume of .2-1.47 mls. It is important to flush the line vigorously to ensure clearance of the fluid in this reservoir.

IVAD Accessing Sterile procedure Flush needle with saline prior to insertion Locate portal septum by palpating it under the skin Scrub entire area to be covered with dressing with chlorhexadine Hold port securely between two fingers. Push the needle at a 90 degree angle to skin Check for blood return, then flush port Ensure sterility at all times while accessing an IVAD. Open your sterile field, and put all your materials on it. Then don sterile gloves, and flush your needle. Ensure that the needle is at a 90 degree angle to ensure proper placement. Most patients lose sensitivity, so it won’t hurt them. There is a hard back of the IVAD, so there is no risk of “poking through”. Good blood return must be noted, if no blood return found, remove needle, and start again. If blood return noted, flush with 20 cc saline, and apply dressing. Either attach lines, or heparinze as needed.

Deaccessing IVAD Use non sterile gloves Flush with saline and heparin Remove old dressing Pull needle out at 90 degree angle

Blood withdraw Stop all infusions and clamp CVAD lumens for 1 minute prior to drawing blood or 3 – 5 minutes if parenteral nutrition is infusing Flush line with 10-20 cc NS (no flush with cultures) Withdraw 3 cc discard (12 cc if coag. studies) No discard if taking cultures Draw samples in order Flush vigorously with 20 cc NS If drawing blood cultures, we do not want to flush the line, or draw a discard. We want to see if anything is growing in the line. Vaccutainors are first choice to use, but if you are finding difficulty with getting the blood, use a syringe to obtain the samples, then transfer the blood to the tubes.

Order of tubes to draw Blood culture tube Coagulation tube (blue) Serum tube with or without clot activator or with or without gel (red) SST tube (gold) Heparin tube with or without gel plasma separator (green) EDTA (lavender) Glycolytic inhibitor (grey) For tubes not listed follow local Lab Services guidelines The main tubes we use are blue (coagulation studies), Green ( chemistry, lytes) and purple (CBC). An easy way to remember is to go alphabetically, B,G,P. It is the same with culture tubes, blue (aerobic) then purple (anaerobic)

Line Occlusion Mechanical obstruction – kinked line Chemical obstruction – incompatible medications Thrombotic obstruction – clot in or around line Assessment: Fully occluded or sluggish blood return Flushes easily, poor blood return Chest X Ray Attempt to flush with 10 cc NS If able, attempt to aspirate blood One complication of using a CVAD is occlusion of the line. There are three main types of occlusion. It is helpful to assess your patient to try and determine the cause of the occlusion, but it is not always obvious. Mechanical obstruction – clamped/kinked tubing, malposition, suture too tight, Huber needle placed incorrectly, migration of tip. Have patient take deep breaths, cough, raise and lower arms, change position. Chemical obstruction – drug interaction (Pharmacy may be able to identify, if occlusion is acid or alkaline) – lipid aggregation Thrombotic – observe head, neck and thorax for signs and symptoms of venous thrombosis or superior vena cava syndrome (e.g. swelling of face, neck and arms) and distension of collateral circulation of the chest. Venous Doppler or flow studies may be indicated. Alteplase works much better on a sluggish line versus a fully occluded line. Can you infuse but not receive blood return? It may be a fibrin sheath that has formed CXR will determine if the cause of poor blood return is due to misplaced catheter end. It may need to be removed instead of declotted. IT can also show if there is a fibrin sheath present. If you are unable to aspirate blood, make sure to trouble shoot. Have patient move or cough. The line could be sitting against the vein wall, or you could be experiencing “pinch off” syndrome.

Fibrin Sheath (second picture is a flouro pic of a sheath) The cause of a fibrin sheath is unclear. With a fibrin sheath the body will form a clot around the catheter. It typically acts as a flap over the end, which opens to infuse fluids, but will close over the opening when trying to withdrawal blood. It also can cause problems with extravasation of chemotherapy. If there are any issues with flushing or blood return, make sure you have the line assessed. There have been documented cases where chemotherapy was redirected up the line due to the fibrin sheath, and extravasated.

Clearing a Blocked Line Alteplase (rt-PA or t-PA) is an enzyme (serine protease) that binds to fibrin in a thrombus and converts the entrapped plasminogen to plasmin, thereby dissolving the clot.

Reconstitution Inject 2.2 mL sterile water into vial Mix by gently swirling until contents are completely dissolved. DO NOT SHAKE Final concentration will be 1 mg/mL Withdraw 2.0 mL (2.0 mg) into a 10 mL syringe Inspect product for foreign matter and discoloration Slight foaming is not unusual during reconstitution; let the vial stand undisturbed to allow large bubbles to dissipate the reconstituted preparation results in a colorless to pale yellow transparent solution

Administration of Alteplase Perform hand hygiene Don protective gloves Ensure catheter lumen(s) are clamped Prior to entering injection cap, cleanse with alcohol, each time Attach 10 mL syringe with alteplase Unclamp the catheter and gently instill the alteplase Reclamp the catheter if needed, and remove syringe Label the catheter lumen, "Alteplase 2 mg in place. DO NOT USE". Indicate date, time & signature. Always ensure that you wash your hands whenever performing a task with a patient. Groshong PICCs do not require clamps This must be done with each lumen of the line, regardless of blood return from each lumen. If there is a fibrin sheath, Alteplasing one lumen is not sufficient to remove it.

Removal of Alteplase Leave line in place two hours Attempt to aspirate 4-5 mLs of blood Flush with 20 mLs NS if able to obtain blood If unsuccessful, repeat procedure with second instillation of alteplase, allowing a dwell time of a minimum of 2 hours. After dwell time, reassess catheter function, may require an overnight dwell You may try to remove alteplase after 30 mins. Alteplase a half life of 45 mins. .if no blood return obtained, flush the lines with NS. Alteplase will be flushed systemically, however, because it has a short half-life, the concentration will be very low If second attempt still does not work, contact physician. You may receive an order to leave it in overnight, or look into fluoroscopy, or removal of the line.

Use of Stopcock for Alteplase Primed 3-way stopcock with injection caps Turnkey “off” To Lumen Empty 10 mL Syringe Visualize a clock and attach injection caps at the 3 and 6 o’clock positions of the 3-way stopcock. Prime the stopcock with alteplase at the 3 o’clock position Remove the alteplase syringe Attach the primed 3-way stopcock to the central venous catheter lumen cap with the turn key pointed “off” towards the lumen Attach an empty 10 mL syringe at 6 o’clock

Use of Stopcock for Alteplase Turnkey “off” to Syringe at 6 o’clock Turnkey “off” to 10 mL syringe 10 mL Syringe Plunger Withdrawn to Create Negative Pressure in Catheter Lumen Re-attach the 10 mL syringe containing alteplase at 3 o’clock. Unclamp the catheter. With the turn key pointed “off” towards 3 o’clock (the alteplase syringe); pull the empty 10 mL syringe plunger back as far as possible, thus creating a negative pressure in the lumen While maintaining the negative pressure on the syringe, point the turn key “off” towards the 6 o’clock position. Note: As the negative pressure resolves the required amount of alteplase necessary to reach the clot occlusion will be pulled into the central venous access device. Clamp catheter Point the turn key “off” to the 12 o’clock position and remove syringes during the dwell time.

PICC Line Removal Reasons for removal of PICC: therapy is complete infection thrombophlebitis occlusion (that does not respond to thrombolytic therapy) damage (that cannot be repaired) venous thrombosis unresolved mechanical phlebitis persistent leaking the line has migrated

Warm Compress Use of Warm Compress may help induce relaxation of the veins, and assist with smooth PICC line removal Often, the veins will go into veinospasm during PICC line removal. The use of a warm compress will help ease with the removal of the line

Routine removal Grasp the catheter close to the exit site without applying any pressure to the cannulated vein or upper arm Use a slow, continuous, ‘pulling’ motion to remove the PICC, keeping the catheter parallel to the skin If resistance is felt, never stretch or use excessive force to remove the catheter which could cause breakage and possible catheter embolism.

Routine removal While withdrawing the final length of the PICC, hold the gauze pad lightly over the exit site. Apply firm pressure to the exit site until all bleeding stops (approximately 5 – 10 minutes) Examine the catheter. Ensure that the tip is intact Note: If the tip is not intact activate code Blue, if possible place tourniquet above exit site to occlude venous return but not arterial blood supply, have patient sit upright and immobilize arm, treat signs/symptoms

Infection suspected Obtain swab for C&S if purulent drainage is present at exit site DO NOT allow the tip of the catheter to touch the skin as it is removed With sterile scissors, cut approximately 2 cm off the catheter tip, ensuring tip does not touch skin. Drop the tip into sterile container and send to the lab for culture

Difficulty with Removal Assess for possible causes Apply gentle tension on the catheter, and tape in place Wait at least 10 minutes and repeat. Re-apply new warm compresses to venous pathway, Provide patient with warm blankets; encourage patient to drink warm liquids Suggest relaxation and distraction exercises (e.g. wrist and hand exercises) Notify physician/NP if catheter removal is unsuccessful If you are having difficulties, the dr/np may order intravenous fluid to hydrate the vein and /or systemic smooth muscle relaxants

Complications of CVAD Air embolism Pneumothorax Catheter malposition and migration Catheter occlusion Damaged or severed catheter Phlebitis Infection There are many complications that can occur as a result of having a CVC. It is estimated that 10 % of patients will experience a complication as a direct result of the CVC. Some of the more common ones are listed as above. Assessment of your patient is very important.

References: RNAO best practice Guidelines Intravenous Nurses Society (2000). Infusion nursing: Standards of practice. Journal of Intravenous Nursing Oncology Nursing Society. (2004). Access device guidelines: Recommendations for nursing practice and education. Pittsburgh: Author. Getting a line on CVAD central vascular access devices Nursing, Apr 2002 by Masoorli, Sue, Angeles, Tess

Recommended Practices for the Prevention of Healthcare Associated Intravascular Device-related Bloodstream Infections Central Venous Catheters (CVC) Part I, Queensland Health Fibrin sheath formation and chemotherapy extravasation: a case report Donna Jo Mayo, Supportive Care in Cancer