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Download Central Venous Catheters (CVC)
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Central Venous Access Venous Devices 1 Content & layout by Karin Sherrill, RN MSN 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 Why Central Lines? 2 Why? Types Types 3 Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Peripheral Site CVC’s Short term (1-3 weeks) Triple Lumen (most common) Intermediate term (1-6 months) PICC Best Practice • Midline (Basilic, Cephalic or Axillary tip) • Central (Superior Vena Cava) Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Long term (> 6 months) Tunneled Implantable Ports Why? Short Term IV Access Types 4 Short Term Intermediate Long Term Open/Closed Dialysis Cath 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 CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw 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 5 6 3-way Stopcocks May be used for ease of access on double or triple lumen ports while keeping unused ports closed. Why? Types Intermediate IV Access 7 Short Term Intermediate Peripherally Inserted Central Catheter Long Term (PICC) Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw 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 8 Why? Long Term Types 9 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 10 11 12 Access Needles 13 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 Dialysis Catheter 14 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 Why? Types CVC – Maintenance / Care Issues 15 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 Why? Types 16 Short Term Intermediate Long Term Open/Closed Dialysis Cath 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 CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Tubings and caps Change per agency protocol 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 Best Practices 17 A. Hand hygiene B. Maximal barrier precautions upon insertion C. Chlorhexidine skin antisepsis D. Optimal site selection –subclavian vein preferred E. Daily review of necessity with prompt removal of unnecessary lines Patient Safety Why? Types 18 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 Why? Patient Safety Types 19 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 Why? Patient Safety Types 20 Short Term Intermediate Open/Closed Utilize CVC lines for hypertonic / caustic solutions or medications/solutions that can cause tissue sloughing if infiltrated Dialysis Cath Long Term pH < 5 or > 9 Solutions with an osmolarity > 500 mOsm/L CVC Flushes Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Prevent infection Always wash hands before handling line / accessing line Keep tubing off the floor Why? Types Short Term Intermediate Long Term Potential Complications 21 Air Embolus (Valsalva and/or Clamp Line) Open/Closed Infection (endocarditis, sepsis) Dialysis Cath Pneumothorax (subclavian / internal CVC Flushes jugular approach) Catheter Migration Thrombus Damage to the vein (stenosis) Vein occlusion Catheter occlusion Site Care Best Practice Pt. Safety PC Insertion D/C Dressing ∆ Blood Draw Why? Types Nursing Role R/T CVC Insertion 22 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 Why? Discontinuing A CVC Types 23 Short Term Intermediate Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice Pt. Safety Discontinue fluids Prep area in the same manner as that used PC Insertion D/C Dressing ∆ Blood Draw 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 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 CVC Dressing Change 24 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/ Why? Types Drawing a Blood Sample from a CVC 25 Short Term Intermediate 1. Long Term Open/Closed Dialysis Cath CVC Flushes Site Care Best Practice 2. 3. 4. 5. Pt. Safety PC 6. Insertion D/C Dressing ∆ Blood Draw 7. 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… 26 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.
