1. Central Venous Catheters and CVP Monitoring Nursing Competency
Presented by:
Jonna Bobeck BSN, RN, CEN

2. Objectives Define indications and contraindications
Discuss complications
Articulate nursing management and care
Discuss prevention of intravascular catheter related blood stream infections per CDC

3. Introduction Common modality Typical sites CVC devices
Central venous catheters (CVCs) are a commonly used modality throughout hospitals and especially in the emergency department and intensive care units, serving a vital role in the management of critically ill patients.By definition, these devices involve placement of a large-bore catheter into one of the body’s main central veins.Typical sites include the internal jugular, subclavian, and femoral veins.Advanced hemodynamic monitoring, transvenous pacemakers, rapid fluid infusion, parenteral nutrition, and selected medications all require reliable central venous access. Central venous catheterization has also gained acceptance in resuscitation and treatment of the critically ill child Although indications vary among critically ill patients, these catheters are usually placed for vasopressor and medication administration, large-volume infusions, phlebotomy, or hemodynamic monitoring. Various CVC devices are available, including introducers, multi-lumen catheters, PICC lines, implantable portable access device’s and hemodialysis catheters.Fortunately the subclavian, jugular, and femoral veins have reliable relationships to easily identifiable surface landmarks and can be accessed quickly. Promising advances in technique, most notably real-time ultrasound guidance, have emerged since the early 2000s that may improve success rates and decrease complication rates.
We will be discussing multi-lumen catheters placed in the subclavian or jugular veins.

4. Insertion Site Selection
Subclavian
Internal jugular
Femoral
Catheter Insertion
Insertion Site
A catheter’s insertion site directly influences the subsequent risk for catheter-related infection. The density of skin flora at the insertion site is a major risk factor for CVC-related BSI. Certain insertion sites are easier to maintain in a clean and dry manner. Catheters inserted into an internal jugular vein are associated with higher risk for infection than those inserted into a subclavian vein. Recent studies suggest the femoral site is associated with a higher risk for deep venous thrombosis than the other two sites. In general, the subclavian site is recommended for infection control purposes. However, this recommendation must be balanced against issues such as patient comfort, anatomic deformity, and risk of mechanical complications (e.g., bleeding and pneumothorax).
Studies have shown that the risk of infection or mechanical complications increases with each needle stick.  If multiple attempts do not result in successful canalization, providers are encouraged to ask for assistance from a more experienced colleague.  

5. Indications Monitoring of the central venous pressure (CVP)
Long term medications
Parenteral nutrition
Caustic medications
Dialysis
Need for frequent intravenous access
Central venous access is indicated for several common clinical situations. If necessary, any central venous approach could be used for each one of these situations. However, experience suggests that certain approaches offer advantages over others in many clinical settings.
Indications for the use of central lines include:[2]
Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid balance
Long-term Intravenous medications
Long-term Parenteral nutrition especially in chronically ill patients
Caustic medications, for example: vasopressors and Chemotherapy
Dialysis
Frequent blood draws
Frequent or persistent requirement for intravenous access
Need for intravenous therapy when peripheral venous access is impossible

6. General
Distorted local anatomy
Extremes of weight
Vasculitis
Prior long-term venous cannulation
Prior injection of sclerosis agents
Suspected proximal vascular injury
Previous radiation therapy
Bleeding disorders
Anticoagulation or thrombolytic therapy
Combative patients
Inexperienced, unsupervised physician
Subclavian Vein
Chest wall deformities
Pneumothorax on the contralateral side
Chronic obstructive pulmonary disease
Jugular Vein
Intravenous drug abuse via the jugular system
Femoral Vein
Need for patient mobility
Contraindications to the various techniques of central venous access are shown here. Most listed contraindications are considered relative, and should be viewed in context with clinical conditions and available options for vascular access. Perhaps the only true absolute contraindication is insertion of catheters impregnated with antibiotic (most commonly tetracycline or rifampin) if the patient has a serious allergy to the drug. Local cellulitis is a relative contraindication to any access route. Each technique is
contraindicated in patients with distorted local anatomy or landmarks. Insertion of catheters through freshly burned regions, although somewhat challenging, does not have a higher incidence of infections until approximately 3 days after the burn when bacterial colonization accelerates.One of the more commonly encountered impediments to CVL is morbid obesity. Surface landmarks are often obscured, an abdominal pannus can block the femoral access site, and deeper insertions and steeper angles are required. The IJ under ultrasound may be a safer approach under these circumstances.Insertion of another catheter to the same side as a preexisting catheter risks the complication of entrapment. Combativeness should be emphasized because the risk of mechanical complications greatly increases in the uncooperative victim. Sometimes, it is best to sedate and intubate critical patients before attempting central venous catheterization. Other relative contraindications include those conditions predisposing to sclerosis or thrombosis of the central veins, such as vasculitis, prior long-term cannulation, or illicit IV drug use via any of the deep venous systems.
Coagulapathy is a frequent concern surrounding CVC insertion, with the overall risk of significant hemorrhage in these patients approximating 2%. A transfusion of fresh frozen plasma is commonly used to correct existing coagulopathy.
SV Approach
SV access is contraindicated in patients who have undergone previous surgery or trauma involving the clavicle, the first rib, or the subclavian vessels; who have undergone previous radiation therapy to the clavicular area; with significant chest wall deformities; and with obesity. However, clinicians in burn centers routinely place central catheters through burned areas. Patients with unilateral deformities not associated with pneumothorax (e.g., fractured clavicle) should be catheterized on the opposite side. Subclavian venipuncture is not contraindicated in patients who have penetrating thoracic wounds unless the injuries are known or suspected to involve the subclavian vessels or SVC. Generally, the vein on the same side of the chest wound should be cannulated to avoid the possibility of bilateral pneumothoraces. When preexisting subclavian vessel injury is suspected, cannulation should occur on the opposite side. Formerly, subclavian venipuncture was not recommended for use in small children, but in experienced hands, it has been demonstrated to be safe.
IJ Approach
Cervical trauma with swelling or anatomic distortion at the intended site of IJ venipuncture is the most important contraindication to the IJ approach. Neck motion is limited when the IJ line is in place, and this limitation represents a relative contraindication in conscious patients. Likewise, the presence of a cervical collar is problematic. Although bleeding disorders are relative contraindications to central venous cannulation, the IJ approach is preferred over the SV route as the IJ site is compressible. In the setting of severe bleeding diatheses, the femoral approach should be considered. Carotid artery disease (obstruction or atherosclerotic plaques) is a relative contraindication to IJ cannulation because inadvertent puncture or manipulation of the artery could dislodge a plaque. In addition, prolonged compression of the artery to control bleeding could impair cerebral circulation if collateral blood flow is compromised. If a preceding SV catheterization has been unsuccessful, the ipsilateral IJ route is generally preferred for a subsequent attempt. In this manner, bilateral iatrogenic complications can be avoided.
Femoral Vein Approach
Contraindications to femoral cannulation include known or suspected intra-abdominal hemorrhage or injury to the pelvis, groin, iliac vessels, or IVC. Palpation for the femoral pulsations in CPR is difficult and is often venous rather than arterial.[45] Ultrasound-guided catheterization under these conditions is faster, more successful, and less likely to incur inadvertent arterial puncture than the standard landmark-oriented approach.[46]

7. Contraindications for Central Line Subclavian Placement Include?
Pneumothorax on contralateral side
A patient who requires CVP readings
Need for normal saline infusion
The need for frequent blood sampling

8. Correct

9. Sorry, Try Again

10. Technique
Advantages
Disadvantages
Basilic (peripheral puncture)
Low incidence of complications
Performed under direct visualization
Allow large quantities of fluid at a rapid rate.
Greater incidence of minor complications
Hinders movement of arm
Increase difficulty for CVP monitoring
Internal jugular
Good external landmarks
Malposition is rare
Nearly a straight course to superior vena cava on right side
Useful alternative to cutdown on children <2 years of age
Slightly higher of failure compared to subclavian
More difficult to secure
Possibly higher infection risk than subclavian

11. Technique
Advantages
Disadvantages
Femoral puncture
Good external landmarks.
Useful alternative to other supradiaphragmatic approaches in patients with coagulopathies or superior vena trauma.
Difficult to secure in ambulatory patients. Generally not reliable for CVP measurement.
Potentially a “dirty” site Higher risk of thrombus.
Subclavian
Practical method of inserting a central line in cardiorespiratory arrest
Unable to compress bleeding vessels.
“Blind” procedure.
Should not be attempted in children younger than 2 yr.

12. Anatomy of Internal Jugular
Figure 22–2  A, Anatomy of the internal jugular (IJ) area. Note that the vein runs nearly parallel, and lateral, to the carotid artery, but the vein is nearly over the artery at the clavicle. Ultrasound obtained during IJ catheterization (B) shows the IJ vein almost directly over the carotid artery above the clavicle (C), demonstrating the value of ultrasound-guided placement of the central venous pressure (CVP) line to avoid arterial injury.

13. Anatomy of Femoral Vein
Figure 22–3  The right femoral vessels. The femoral nerve (not shown) lies lateral to the artery and may be deep to the artery. Note that distal to the inguinal ligament, the femoral artery starts to move medially and almost on top of the femoral vein. Attempts low in the groin may, without ultrasound guidance, injure the artery.

14. Anatomy of the Subclavian
Here in figure A is the, Anatomy of the subclavian and internal jugular veins. Figure B,shows Sagittal section of the subclavian area. Note the position of the clavicle, subclavian vein and artery, and lung. If the needle is kept almost parallel to the clavicle, the artery and lung will not be encountered. 

15. Hand Washing Fingernails Hand hygiene Fingernails &Handwashing
Hand washing is an extremely effective way to prevent nosocomial infections, but fingernails often harbor microorganisms after thorough hand cleansing. Lengthy or artificial fingernails increase this tendency for pathogenic organisms to remain on the hands. For this reason, the Association of Operating Room Nurses has officially banned artificial nails in the operating room.  In general, health care providers should avoid wearing artificial nails at work and should keep their nails neatly trimmed.  (Of note, Vanderbilt has a policy prohibiting providers with direct patient contact from wearing artificial nails at work -- refer to Dress Code Policy available online here)
Hand Washing
Good hand hygiene before catheter insertion or maintenance is important for reducing CVC-related infections. Even if providers wear gloves, studies have consistently shown that hand washing immediately prior to the handling of a line reduces the incidence of infections. Use of a waterless, alcohol-based gel is at least as effective as traditional soap and water. All VUMC staff are expected to adhere to good hand hygiene practices both before and after contact with patients and their environment (see Hand Hygiene Policy available here).

16. Patient Positioning Jugular access Subclavian access
Increased jugular vein diameter is associated with increased cannulation success [81,85,86]. The compliant jugular vein distends with increased hydrostatic pressure due to positioning, respiratory cycle, and intrathoracic pressure. Employ maneuvers to enhance jugular vein size. Position the patient in a head-down (Trendelenburg) position of 10 to 15 degrees to significantly increase jugular size compared to flat positioning [77,81,85-88]. Ask cooperative patients to hum or perform a Valsalva maneuver. If the patient is not awake or is unable to cooperate, apply abdominal compression to increase venous dimension
Place the patient in the supine position with the head down (Trendelenburg) approximately 10 to 15 degrees. Adduct the patient's arms. In contrast to the jugular vein, Trendelenburg positioning does not affect subclavian size substantially but should be utilized to prevent air embolus [97,98]. Place a small sandbag or rolled towel between the scapulae to retract the shoulders and facilitate needle insertion by reducing the deltoid prominence [27]. The maneuver also positions the vein closer to the clavicle for a more consistent relationship [98,99]. Do not use excessive retraction as it reduces the anterior-posterior dimension of the vein [

17. The Central Line Bundle
Hand hygiene
Maximal barrier precautions
Chlorhexadine skin antisepsis
Optimal site selection
Prompt removal
The Central Line Bundle
Care bundles, in general, are groupings of best practices with respect to a
disease process that individually improve care, but when applied together result
in substantially greater improvement. The science supporting each bundle
component is sufficiently established to be considered the standard of care.
The central line bundle is a group of evidence-based interventions for patients
with intravascular central catheters that, when implemented together, result in
better outcomes than when implemented individually.
The central line bundle has five key components:
1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter site selection, with subclavian vein as the preferred site
for non-tunneled catheters
5. Daily review of line necessity, with prompt removal of unnecessary lines
Compliance with

18. Skin Prep Chlorhexadine side to side scrub x 2 Clip hair, do not shave
Although povidone-iodine (Betadine) has been the most widely used antiseptic, 2% aqueous chlorhexidinegluconate is actually superior for reducing CVC-related BSIs. Unless contraindicated, use 2% chlorhexidine for skin antisepsis. If the patient is allergic to chlorhexidine, use povidone-iodine. Scrub side to side x2 and Allow the antiseptic to air dry on the site before insertion.   
If hair must be removed prior to line insertion, clipping is recommended. Shaving is not appropriate because razors cause local skin abrasions that subsequently increase the risk for infection.

19. Maximal Barrier Precautions
Strict sterile conditions
Maximum Barrier Precautions
Full bed drape
Sterile Gown
Sterile Gloves
Surgical mask for anyone with in three 3 feet of insertion site
Head cover for anyone with in 3 feet of insertion site
Maximal Barrier Precautions
Compared with peripheral venous catheters, CVCs carry a substantially greater risk for infection. Therefore, central lines should always be placed using maximal sterile barrier precautions (persons placing the CVC should wear a cap, mask, sterile gown, and sterile gloves, and a large sterile drape should cover the patient's head and extend below the waist. Hair cover and mask for anyone else within 3 feet of the patient).  Studies have consistently shown that the use of maximal barrier precautions reduces the incidence of CVC-related BSIs when compared against standard precautions (sterile gloves and sterile towels). Of note, maximal barrier precautions are also recommended for any guidewire exchanges.

20. Equipment Equipment for CVP insertion procedure:
CVP insertion kit at prh the pressure injectable quad lumen cvc kit has all the equipment except microclave clear caps and pressure tubing setup.
Maximum barrier precaution kit: Surgical masks, surgical caps, sterile gloves, full bed drape, and sterile gown
Chlorhexidine skin preparation
Sterile drapes or towels.
Ns for flush
10 ml syringe
Heparin flush 10 units per ml: Flush each lumen with 2.5ml
Disposable transducer with pressure tubing see Patient Care Policy # T-1 Transducer leveling and zeroing of disposable.

21. Procedure Wash hands Prepare IV flush Prepare pressure tubing
Monitor patient
Obtain appropriate equipment
15-25 degree Trendelenberg
Flush ports
Obtain CXR
Procedure / Preparation
Explain procedure/obtain consent
Wash Hands
Prepare 10ml syringes for flush
Prepare pressure tubing if indicated for CVP
Monitor patient’s vital signs, O2 saturation, and EKG rhythm for arrhythmia
continuously during the procedure.
4. Obtain appropriate equipment.
Maximum Barrier Precautions
Full bed drape
Sterile Gown
Sterile Gloves
Surgical mask for anyone with in three 3 feet of
insertion site
Head cover for anyone with in 3 feet of insertion site
Place the bed in a degree Trendelenberg position to prevent air embolism
Each port is to be aspirated and capped with microclave clear caps. Heparin flush 10 units per ml: Flush each lumen with 2.5ml
Place disinfecting port protectors on all unused ports for central line and IV tubing
Place a sterile, occlusive dressing complete with biopatch and opsite.
Obtain a chest x-ray Improper catheter tip position occurs commonly. It has been reported that only 71% of SV catheters are located in the SVC on the initial chest film. Complications of improper positioning include hydrothorax, hemothorax, ascites, chest wall abscesses, embolization to the pleural space, and chest pain. More commonly, improper location yields inaccurate measurements of the CVP or is associated with poor flow caused by kinking. An unusual complication caused by improper tip position is cerebral infarction, which can occur following inadvertent cannulation of the subclavian artery.

22. Post Procedure CONFIRM placement Distal lumen Adjust scale procedure:
􀂾 Order a Chest x-ray to confirm placement of catheter (do not infuse any fluid into the catheter until confirmation of placement has been made by the MO.)
􀂾 . The distal lumen (brown) is the preferred choice of lumens for CVP measurement.
􀂾 Adjust scale and set appropriate alarm parameters
􀂾 Allow patient back into semi-fowlers position if applicable
􀂾 Ensure line and insertion site is free of tension

23. Documentation Patient and family education Vital signs
Hard copy of waveform
Catheter location
Date and time
Nursing interventions
Patient tolerance
dressing
Documentation:
Patient and family education
VSS, hard copy of waveform if monitoring
Catheter location, gauge / french, # of lumens, length of catheter and centimeter markings, lot number
Date and time of procedure
Nursing interventions
Patient tolerance of procedure
Type of Dressing applied
Placement confirmed by chest x-ray (write as order)

24. Ports

25. Central Venous Pressure
Blood from systemic veins flows into the right atrium; the pressure in the right atrium is the central venous pressure (CVP). CVP is determined by the function of the right heart and the pressure of venous blood in the vena cava.
In normal health the amount of blood coming to the heart is balanced precisely by the amount of blood leaving the heart. When there is blood loss or other alteration in the cardiovascular system’s homeostatic mechanism it will first be reflected in changes of the venous pressure at this point. As a rule of thumb the central venous pressure is a good indicator of the amount of blood returning to the heart from the systemic circulation. Further, it (CVP) is a good indicator of the pumping ability of the right atrium and the right ventricle. When the right atrium or ventricle is failing (e.g. following right atrial or ventricular MI) the CVP will be one of the first indicators to rise. The rising CVP indicates that the atria and/or ventricle are failing.

26. Measuring CVP Gather equipment Plug transducer cable into red port
Prepare pressure tubing
- Use heparin 1000 units/500 ml
1. Gather equipment as described
2. Turn on the Philips monitor and attach transducer cable to red port. The CVP monitoring will show up on the screen in red.
3. Prepare the pressure monitoring system. Spike the 1000 units/500ml heparin bag with IV pressure tubing and remove all air from the bag. Attach the flush solution to the IV tubing portion of the pressure tubing set and fill the drip chamber half full to prevent air from entering the system. Prime the tubing and transducer to remove all air from the system. This is accomplished by opening the roller clamp and pulling blue pigtail. Work down the tubing and flush each stopcock. Replace each vented cap with non-vented caps. Continue until all air is removed from the system. inspect the entire system for air, epically the transducer as air can cause a dampened waveform. Tap out any air bubbles that adhere to the tubing within so they can be flushed out at the nearest stopcock. Turn each stopcock on to both the patient and transducer.
4. Place the heparin bag into a pressure bag and pressurize to 300mmg hg. This step is not performed before the previous because the increased pressure causes rapid flushing and increased turbulence, which may trap air bubbles in the system causing a dampened waveform.
5. Attach the transducer cable to the pressure tubing (remember the white pigtail goes down).

27. The phleobostatic axis marked on the patients chest is the precise anatomical point of origin of the hemodynamic pressure being monitored
Secure the transducer on the iv pole at the level of the right atrium so that the stopcock at the air fluid interface (the same stopcock that is used to open the system to atmospheric pressure) is at the level of the phleobostatic axis. A level should be used to guide placement. The phlebostatic axis is found by locating the junction of the fourth intercostals' space and mid axillary line.
7. Zero balance the transducer. Zeroing the system to the atmospheric pressure negates the effects of the atmospheric pressure. To prevent erroneous pressure readings, zero the system before and after the pressure system is attached to the patient. To zero, turn the stopcock next to the transducer off to the patient and open it to air by twisting and removing the dead end cap (remember this is a closed system and keep all parts sterile). Press “zero” button on monitor. The monitor will beep and show a “zero”
Once connected to port Flush any back flow of blood through tubing using the pigtail near the transducer.
Observe the monitor for correct CVP pressure waveform. Obtain each CVP reading with the patient in the same position usually flat supine, may elevate the hob 30 degrees for head injured patients.
Set monitor alarms as determined by patients condition or physician order.

28. The a wave indicates right atrial systole; it is followed by the x decent, which indicates the drop in pressure that occurs during right atrial relaxation. The c wave, which may not be distinguishable on the waveform is caused by bulging of the closed tricuspid valve into the atrium during right ventricular systole; the x decent following the c wave. The v wave indicates right atrial diastole, when blood is filling the atrium; it is followed by the y decent, which indicates the passive right atrial emptying of blood into the right ventricle through the open tricuspid valve.
Various changes in the CVP waveform can indicate pathophysiological changes in the heart and pulmonary vasculature. An elevated a wave is seen in tricuspid stenosis, right ventricular hypertrophy secondary to pulmonic valve stenosis, or pulmonary hypertension, constrictive pericarditis and cardiac tamponade, all of which impede right atrial emptying.
An elevated v wave is caused by tricuspid insufficiency, with backflow of blood into the right atrium during ventricular systole thus causing an increase in pressure. Tricuspid insufficiency can also cause an absence of the c wave, since the valve is incompetent and will not bulge back into the right atrium during ventricular systole.
Cannon waves (combined a and c waves) occur whenever the atrium contracts against a closed valve; for example, when junctional or ventricular beats occur, the atria contract out of sequence and the valve is closed because of ventricular systole. The cannon waves are large and obscure the v wave,

29.   The central venous waveform seen on the monitor reflects the events of cardiac contraction; the central venous catheter “sees” these slight variations in pressure that occur during the cardiac cycle and transmits them as a characteristic waveform.  There are three positive waves (a, c, and v) and two negative waves (x and y), and these correlate with different phases of the cardiac cycle and EKG.
THERE ARE 2 WAYS TO READ THE CVP WAVEFORM
1. Find the mean of the A wave.
read the high point of the A wave
read the low point of the A wave
add the high point to the low point
divide the sum by 2
the result is the mean CVP
The A wave starts just after the P wave ends and represents the atrial contraction. The high point of the A wave is the atrial pressure at maximum contraction. During the A wave the atrial pressure is greater than the ventricular diastolic pressure. At that point, the atrium is contracted, the tricuspid is open. Therefore, the high point of the A wave closely parallels the right ventricular end diastolic pressure. Remember, when the tricuspid valve is open and the right ventricle is full, the ventricle, atrium and vena cavae are all connected. Therefore, that point is the CVP.
2. Find the Z-point.
Find the Z-point which occurs mid to end QRS
Read the Z-point
The Z-point coincides with the middle to end of the QRS wave. It occurs just before closure of the tricuspid valve. Therefore, it is a good indicator of right ventricular end diastolic pressure. The Z-point is useful when A waves are not visible, as in atrial fibrillation.(The c-wave occurs at closure of the tricuspid valve. The crest of the c-wave is the atrial pressure increase caused by the tricuspid valve bulging back into the atrium.)
Because the CVP may fluctuate, analyze values for trends rather than attaching great significance to isolated values. The CVP value should be interpreted in conjunction with the patient’s clinical status and history.
The waveform may fluctuate with respirations; readings should be taken at end-expiration to minimize the influence of intrathoracic pressure.

30. CVP Assessment 2-6 mm Hg Elevated CVP Low CVP
Because determination of the CVP can aid the clinician in assessment of the critically ill patient, it is paramount that the clinician know the normal values and the variables that may affect these values and can recognize the pathologic conditions that correlate with abnormal values. NORMAL RANGE IS 2-6mmHg
CVP is elevated by :
overhydration which increases venous return
heart failure or PA stenosis which limit venous outflow and lead to venous congestion
positive pressure breathing, straining,
CVP decreases with:
hypovolemic shock from hemorrhage, fluid shift, dehydration
negative pressure breathing which occurs when the patient demonstrates retractions or mechanical negative pressure which is sometimes used for high spinal cord injuries.

31. Port a Cath and PICC Lines
Click link to review PRH policy
-IV Therapy Policy

32. Reading CVP Waveforms is Fun!!

33. References
Lynne-MChaleWiegard, D., Carlson, K., Initials. (Ed.). (2001). Aacn procedure manual for critical care. United States: Elsevier Saunders.
Proehl, J. (Ed.). (2004). Emergency nursing procedures. United States: Elsevier Saunders