Central Venous Access Venous Devices Content & layout by Karin Sherrill, RN MSN

Why Central Lines? Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw

Types Peripheral Site CVC’s Short term (1-3 weeks) Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Peripheral Site CVC’s Short term (1-3 weeks) Triple Lumen (most common) Intermediate term (1-6 months) PICC Midline (Basilic, Cephalic or Axillary tip) Central (Superior Vena Cava) Long term (> 6 months) Tunneled Implantable Ports

Short Term IV Access Triple Lumen Catheters (TLC’s) Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Triple Lumen Catheters (TLC’s) Volume = 0.53 to 0.94 mL, lumens = 18/16 gauge Rigid & stiff (polyvinyl catheter material) Can damage intima of vessel Carries a risk of platelet aggregation and subsequent thrombus formation Inserted via the Internal Jugular or Subclavian Vein, often sutured in place Usually open-tipped and requires Heparin/ Positive Pressure Cap to prevent clot formation

3-way Stopcocks May be used for ease of access on double or triple lumen ports while keeping unused ports closed.

Intermediate IV Access Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Peripherally Inserted Central Catheter (PICC) Volume = 0.33cc per lumen, lumens have gauge sizes Soft & Pliable (Silicone / Polyurethane material) Less damaging to intima of vessel than rigid material catheters Less likely to cause platelet aggregation / thrombus formation than rigid catheters Measurement of arm circumference and length of exposed catheter are documented daily Measure and document length of exposed catheter per policy

Long Term Tunneled Catheters: Hickman/Broviac/Groshong Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Tunneled Catheters: Hickman/Broviac/Groshong Silicone with a Dacron polyester cuff Cuff embeds in the scar tissue with fibroblasts within 7-10 days – no suture required Cuff protects from bacterial colonization Seen often in patients receiving chemotherapy Implanted Vascular Access Devices: Port-a-Cath /Infus-a-Port Port is made of Titanium / Plastic which is attached to a silicone catheter Port is self sealing, MUST use non-coring needle to access port (Huber needle) Use sterile technique to access implanted devices

Under the skin- Implanted – VADs, VAPs, Ports

Access Needles

Dialysis Catheter Perma Cath Hemodialysis Catheter Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Perma Cath Hemodialysis Catheter Packed with higher concentrations of Heparin Should never access or use without specific order or standing protocol (Life Line!!!) Even dressing changes are done by the dialysis nurse

CVC – Maintenance / Care Issues Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Flushes – Per Agency Protocol Use 10cc size syringe WHY? Use saline and/or heparin volumes as recommended per agency protocol (SAS or SASH) Use the push-pause technique for flushing At completion of flush apply positive pressure to the plunger while removing needle/syringe from the cap

Site Care Site Care Assess the site every 4-8hrs. Assess dressing Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Site Care Assess the site every 4-8hrs. Assess dressing Should be occlusive and secure at all times Change dressings every 24hrs (gauze dressings or Neutropenic patient dressings), 72hrs (transparent dressing without biopatch), 7 days (transparent dressing with biopatch) or PRN if soiled or wet Tubings and caps Change per agency protocol

Best Practices Hand hygiene Maximal barrier precautions upon insertion Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Hand hygiene Maximal barrier precautions upon insertion Chlorhexidine skin antisepsis Optimal site selection –subclavian vein preferred Daily review of necessity with prompt removal of unnecessary lines

Patient Safety Prevent air embolus / exsanguination/ infection Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Prevent air embolus / exsanguination/ infection Place caps on all lumens of a CVC Keep the clamps on all capped lumens in the closed / off position when pressure port not in place Use sterile technique to change or disconnect caps or lines Remove all air from syringes and IV tubing before connecting to the patient Crimp line / use slider clamp / have patient perform Valsalva / place the HOB flat when discontinuing a CVC or when changing caps / tubings

Patient Safety Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Secure tubing to prevent excess weight on the catheter (helps prevent catheter migration) Blood draws from CVC’s require a physician’s order / agency policy Follow agency policy / protocol for discontinuing / declotting lines Always assess patient for s/s of complications after insertion of CVC

Patient Safety Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Utilize CVC lines for hypertonic / caustic solutions or medications/solutions that can cause tissue sloughing if infiltrated pH < 5 or > 9 Solutions with an osmolarity > 500 mOsm/L Prevent infection Always wash hands before handling line / accessing line Keep tubing off the floor

Potential Complications Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Air Embolus (Valsalva and/or Clamp Line) Infection (endocarditis, sepsis) Pneumothorax (subclavian / internal jugular approach) Catheter Migration Thrombus Damage to the vein (stenosis) Vein occlusion Catheter occlusion

Nursing Role R/T CVC Insertion Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Consent Sterile Procedure Positioning Head dependent/trendelenburg Rolled towel under shoulder Flushes drawn up and ready Post insertion CXR required before use to validate proper position of tip of catheter Pneumothorax is also evaluated if the patient had a CVC placed in the subclavian or jugular veins

Discontinuing A CVC Discontinue fluids Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Discontinue fluids Prep area in the same manner as that used to change a CVC dressing Cut suture Patient flat (and put arm perpendicular to body for a PICC) Have patient perform Valsalva Remove gently and quickly (use momentary pauses when discontinuing a PICC line) Why? Hold pressure over insertion site x 5 min. Apply occlusive dressing x 48 hours

CVC Dressing Change General guidelines http://itunes.mc.maricopa.edu/ Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw General guidelines Every 72 hours if no biopatch Every 7 days if biopatch in place Every 24 hours if gauze dressing in place Every 24 hours if patient is Neutropenic Change if soiled or wet or insertion site is not covered http://itunes.mc.maricopa.edu/

Drawing a Blood Sample from a CVC Why? Types Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Stop continuous infusions on other lumens for at least a minute Aseptically prepare appropriate lumen port Flush line with normal saline (5-10cc’s) Waste 5cc of blood Withdraw desired amount of blood for sample needed Flush line with 10-20cc’s normal saline (if capped line assess need for heparin flush) Resume infusion

Think Like a Nurse… Order states: Administer 80mg Solu-Medrol IV q12H. Vial has 125mg in 2mL. Your patient has a single lumen PICC Line infusing TPN. Your patient has a peripheral IV saline lock.