2.  Introduced in early 1980s  Allow medications to be delivered directly into larger veins  Less likely to clot  Can be left in for longer periods of time

3.  Central Venous Catheters › Tunneled CVC’s:  Hickman  Broviac  Groshong › Percutaneous CVC’s:  Ports  PICC Lines  Fistulas

4.  Surgically inserted  Tunnel made through subcutaneous tissue (usually b/t clavicle and nipple)  Tip inserted through cephalic, internal or external jugular and threaded into superior vena cava  Held in place with Dacron cuff under skin  Placement verified through x-ray  Can be single, double or triple lumen

5. Placement of Tunneled CathetersTunneled Catheters

6. First used in oncology patients in 1981; now 100,000 ports implanted yearly Surgically implanted beneath skin, usually in chest region Right side of chest preferable d/t anatomy (superior vena cava) – “kangaroo” pocket created for portal body Accessed by IP, Huber, or other type of needle with deflective, non-coring tip

7. Placement of portsPort Images

8.  Long term IV therapy  Frequent blood transfusions or blood draws  Bone marrow transplant  Protection of smaller vessels

9.  Advantages › Decreased chance of infection – port sealed under skin › Less interference with ADLs – no external components › Less body image concerns (teens) › Long usable life – up to 10 years (compared to <1 yr for PICC line)  Disadvantages › Needle access › Most expensive device to place › Requires minor surgical procedure for placement › Can be difficult for patients to maintain

10. PICC – Peripherally Inserted Central Catheter Inserted in interventional radiology or patient room by: Physician Physician Assistant Nurse Practitioner Certified PICC nurse specialist Placed in peripheral vein (basilic, cephalic or brachial) and advanced into superior vena cava or cavo-atrial junction

11. Healthcare providers often use ultrasound for placement followed by x- ray (fluoroscopy)to assure proper placement

12.  Reduced number of needle punctures  Prolonged IV antibiotic treatment  TPN nutrition  Chemotherapy  Repeated administration of blood or blood products  Venous blood samples  Measurement of central venous pressure

13. Used for dialysis in patients with renal impairment Surgeon joins an artery and vein, bypassing capillaries, allowing blood to flow rapidly through the fistula Created in the non-dominant arm If vein quality is poor, grafts can be used Takes approximately 4-6 weeks to mature

14. Formation of fistulas Aneurysm of fistula

15. Radiocephalic Brachiocephalic  Most common fistula for hemodialysis  Created in forearm near wrist  Radial artery anastomosed to cephalic vein  Often created if poor lower arm vessels or after failure of radiocephalic fistula  Created in arm near elbow  Brachial artery anastomosed to cephalic vein

16.  Benefits: › Lower infection rates › Higher blood flow rates = more effective dialysis › Lower incidence of thrombosis  Complications: › “Steal syndrome” = cold limb, cramping, tissue damage › Aneurysm d/t repeated needle insertion › Thrombosis › Failure to mature

17. Two needles inserted into fistula, one to draw blood, one to return it

18.  Bartholomay, M., Dreher, D., Evans, T., Finn, S., Guthrie, D., Lyons, H., Mulligan, J., & Tyksienski, C. (n.d.) Nursing management of venous access devices: Non-tunneled catheters. Retrieved from http://www.mghpcs.org/EED_Portal/Documents/Central_Lines/CL_Module7. pdf http://www.mghpcs.org/EED_Portal/Documents/Central_Lines/CL_Module7. pdf  Nursing Link (2012). The use and maintenance of implanted port vascular access devices. Retrieved from http://nursinglink.monster.com/training/articles/302-the-use-and- maintenance-of-implanted-port-vascular-access-devices http://nursinglink.monster.com/training/articles/302-the-use-and- maintenance-of-implanted-port-vascular-access-devices  Queensland Vascular (n.d.) Vascular and endovascular surgery. Retrieved from http://www.qldvascular.com.au/renal-clinic.htmlhttp://www.qldvascular.com.au/renal-clinic.html  Roe, E. J., III, & Turner-Lawrence, D. (2012). Central venous access via subclavian approach to the subclavian vein. Retrieved from http://emedicine.medscape.com/article/80336-overview http://emedicine.medscape.com/article/80336-overview