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A
M
United States
Arrow International, Inc.
3000 Bernville Road
Reading, PA 19605
610-378-0131
Call toll-free 800-523-8446
Orders-only toll-free fax: 800-343-2935
Fax: 610-478-3199
P
R R O W
U L T I P L E
T W I N C A T H
L
U M E N
C
A T H E T E R
E R I P H E R A L
Canada
Arrow Medical Products, Ltd.
150 Britannia Road East, Unit #20
Mississauga, Ontario L4Z 1S6
Call toll-free 800-387-7819
or in Toronto 416-890-0173
Nu r s i n g
Europe
Arrow Deutschland G.m.b.H.
P.O. Box 1438
Robert-Koch-Str. 9
D-85435 Erding, Germany
Phone: 8122-3026
Fax: 8122-40384
Ca r e
Arrow France S.A.
Parc d’activité de Medicis
Bâtiment 63
94260 Fresnes, France
Phone: (1) 46 68 04 04
Fax: (1) 46 68 55 88
Gu i d e l i n e s
Arrow Holland Medical Products B.V.
P.O. Box 275
3900 AG Veenendaal, Netherlands
Phone: 83-8510465
Fax: 83-8527334
Japan
Arrow Japan, Ltd.
9-10F Chiyoda Asahi Building
2-8-3 Iidabashi Chiyoda-ku, Tokyo 102
Phone: 03-3222-5498
Fax: 03-3222-5396
Africa
Arrow Africa (Pty.), Ltd.
7 Sandton Commercial Village
Marlboro Drive Sandton
P.O. Box 1716
Kelvin 2054
Republic of South Africa
Phone: (011) 444-0550/1/2
Fax: (011) 444-0519
twin
cath
Arrow Japan, Ltd.
Shin-Osaka Kita Bldg. 4F
1-46 Miyahara 4-chome
Yodagawa-ku, Osaka 532, Japan
Phone: 06-397-7070
Fax: 06-397-7575
®
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INTRODUCTION AND
CHARACTERISTICS
FEATURES
features
multiple lumen
peripheral catheter
The distal lumen is
i d e n t i f i e d by its blue (18 Ga.) or
white (16 Ga.) luer lock hub. The
proximal lumen is identified by the easy to
handle clear extension line also with a luer
lock™ fitting and UserGard™ injection
cap. All lumens are clearly marked with
their individual gauge sizes.
I n t r o d u c t i o n : Increased reliance
on the use of the intravenous route has
resulted in a need for simultaneous but
separate venous access sites. This need
has led to the development of a multiple
lumen peripheral catheter that helps
conserve peripheral sites, reduce patient
discomfort and is cost effective.
Because there is great diversity from one
institution to another, the information
and procedures listed are intended to
serve only as guidelines for successful use
of the Arrow TwinCath®.
The luer lock hub design permits use of
luer lock tubing and prevents accidental
disconnects. When needles are used the
UserGard™ injection cap is longer in
length to reduce the risk of extension line
puncture and to permit visualization of
the needle tip. The injection cap
diaphragm can also accommodate the
Arrow UserGard hub, a needle free
product designed to reduce the risk of
needlesticks. A flexible hub/catheter
transition helps to minimize kinking and
aids in patient comfort. A removable slide
clamp on the extension line permits easy
line changes. The small introducer needles
(20 Ga. or 22 Ga.) provide for easier vein
cannulation. A 0.45 micron vent plug
prevents blood seepage upon vein entry.
18 Ga. Catheter
Cross Section
22 ga. Proximal
C h a r a c t e r i s t i c s : The Arrow
TwinCath® is the first and only
polyurethane multiple lumen over-theneedle catheter designed for peripheral
placement. The catheter consists of two
separate and distinct non-communicating
lumens which DO NOT permit mixing of
infusates within the catheter.
20 ga. Distal
Also available as 16 Ga.
catheter with 18 Ga. and
20 Ga. Lumens
The catheter is available in both 18 Ga.
and 16 Ga. models. The 18 Ga. catheter
has a 20 Ga. distal lumen and a 22 Ga.
proximal lumen while the 16 Ga. catheter
has an 18 Ga. distal lumen and a 20 Ga.
proximal lumen. The useable catheter
length is 1-3/4 inches.
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FEATURES
TWIN CATH® INSERTION SITES
PRIMING VOLUMES AND FLOW RATES
Pre-attached
UserGard™
injection site
priming volumes
and flow rates
Proximal lumen
luer lock hub
Clearly
marked
proximal
lumen
*Priming Volumes:
Removable
Slide Clamp
Distal lumen
luer lock hub
Catheter
Gauge
Distal
Lumen
Proximal
Lumen
18 Ga.
20 Ga.
0.07 ml
22 Ga.
0.13 ml
16 Ga.
18 Ga.
0.10 ml
20 Ga.
0.21 ml
**Flow Rates:
Flexible
kink-resistant
hub/catheter
junction
Polyurethane
catheter
material for
improved
indwelling
characteristics
Catheter
Gauge
Distal
Lumen
Proximal
Lumen
18 Ga.
20 Ga.
3110 ml/hr
22 Ga.
960 ml/hr
16 Ga.
18 Ga.
4235 ml/hr
20 Ga.
1815 ml/hr
Twin Cath® insertion sites
Preferred placement
Separate
infusion ports
for simultaneous
infusions and/or
discrete blood
sampling
Unique
flow-designed
separation of the
infusion ports
sites for the TWIN CATH®
Clearly
marked
distal
lumen
are the major venous
c h a n n e l s of the arm, i.e. cephalic,
basilic, median cubital and axillary, as
shown to the right.
*Priming volume of proximal lumen
excludes injection cap. UserGard™ injection
cap volume is 0.17 ml.
Hydrophilic
coating for
easier
insertion
**Flow rates are determined with normal
saline, room temperature,
40 inch head height and represent
approximate flow capabilities.
Tubex® Blunt Pointe™ sterile cartridge units are compatible with Arrow
UserGard™ Intermittent Injection Caps. Tubex® Blunt Pointe™ is a registered
trademark of Wyeth-Ayerst Laboratories.
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TWIN CATH® INSERTION SITES
INDICATIONS
The total blood flow
FOR
USE
indications for use
through the human arm varies with
the patient’s cardiac output and
vasomotor tone. It is predicted that
3-5% of the total cardiac output goes
to the resting arm. About one-half of
this blood is then returned to the
heart by the superficial venous
channels at a rate of approximately 75 to 175 ml/min.1,3
Reproduced with permission from: Plumer,
AL. Principles and Practices of Intravenous
Therapy. 4th ed. Boston, Mass: Little Brown
and Co. 1987
1.
Patients requiring two individual peripheral sites.
2.
Patients with minimal or decreased peripheral
venous access.
3.
Patients receiving two or more incompatible drugs
with no central access.
4.
Patients receiving thrombolytic therapy where
venous access needs to be maximized while limiting
actual puncture sites (central vein cannulation is
contraindicated unless critical).
5.
Patients requiring PPN (peripheral parenteral
nutrition) and medication therapy.
6.
Patients utilizing PCA (patient controlled
analgesia).
Basilic Vein
Brachial Artery
Cephalic Vein
Accessory Cephalic Vein
Radial Artery
Median
Cubital Vein
Basilic Vein
Cephalic Vein
Ulnar Artery
Median
Antebrachial
Vein
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INSERTION PROCEDURE
INSERTION PROCEDURE
insertion procedure
15. Hold the clear introducer needle hub in position,
and advance the catheter forward into the vessel.
Remove the introducer needle.
U s e s t e r i l e t e c h n i q u e and follow
PRECAUTION: Do not reinsert the needle into
the catheter.
universal blood and body fluid precautions.
11. Prepare the puncture site in a suitable manner.
16. Attach a desired stopcock, injection cap or
connecting tubing to the distal hub. Do not begin
the infusion until proximal lumen placement is
verified.
12. Prepare the catheter for insertion by flushing the
proximal port through the injection cap as follows:
Leaving the needle guard in place hold the
catheter in an upright position. Flush with normal
saline or heparin flush solution to activate the
catheter’s hydrophilic coating.
PRECAUTION: In order to avoid problems
associated with disconnects, it is recommended
that only luer lock fittings be used with this
device.
PRECAUTION: Do not allow the flush solution
to go beyond the tip of the catheter.
17. Check the proximal lumen placement. Aspirate
blood from the proximal port through the
extension line, then flush.
Allowing the flushing solution to go beyond the
catheter’s tip might partially or totally occlude the
introducer needle and interfere with flashback.
13. Puncture the vessel using a continuous, controlled
slow forward motion, being careful to avoid
transfixing both vessel walls. Blood flashback in
the clear hub of the introducer needle indicates
successful entry into the vessel. Aspiration may be
required.
18. Attach the proximal hub to a desired connecting
line, or, if desired, the proximal port may be
“locked” through the injection cap. A slide clamp
is provided to occlude flow through the proximal
lumen for cap and line changes.
PRECAUTION: Open the clamp prior to
infusion.
19. Secure the catheter to the patient. Begin infusion
through the distal lumen, if ordered.
14. After entering the vein, advance the catheter and
needle as a unit, approximately 1cm, to ensure
that vessel dilation is complete.
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INSERTION PROCEDURE
GUIDELINES
guidelines for
infusion of incompatible medications
10. Cover the puncture site with a suitable sterile
dressing.
PRECAUTIONS: Care should be exercised that
the indwelling catheter does not come in contact
with high concentrations of alcohol or 100%
acetone solution, which could weaken the
catheter and cause leakage.
The ability to administer several medications
simultaneously through a single peripheral catheter site
is very desirable in the clinical setting. The TwinCath®
has two separate, non-communicating lumens which
allow the simultaneous administration of two different
intravenous solutions. Incompatible infusates cannot
interact within the catheter.
To use proximal port for blood sampling,
temporarily shut off distal port.
Complications associated with intravenous
catheters include infiltration, catheter embolism,
bacteremia, septicemia, thrombosis, inadvertent
arterial puncture, nerve damage, hematoma,
intravascular clotting and hemorrhage.
Determinants of Incompatible
Medication Administration3
Due to the risk of exposure to HIV (Human
Immunodeficiency Virus) or other blood-borne
pathogens, healthcare workers should routinely
use “universal blood and body-fluid precautions”
in the care of all patients.
There are four principal determinants for the safe
administration of incompatible medications through
different ports of the TwinCath®. They are:
11. The amount of venous blood flow going by the
catheter.*
Intravenous catheter should be routinely
inspected for flow rate, security of dressing and
possible migration. To avoid cutting the catheter
do not use scissors or other sharp instuments to
remove dressing,
12. The concentration of the medications as they exit
the catheter.
13. The rate of injection of the two medications.
14. The chemical characteristics of the incompatible
drug interaction.
Use of a syringe smaller than 10ml to irrigate or
declot an occluded catheter may cause
intralumenal leakage or catheter rupture.7
* Dependent upon cardiac output and
peripheral circulation.
PRECAUTION: Limit placement of the
TwinCath® to the large venous channels
of the upper arm and forearm.
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GUIDELINES
BLOOD SAMPLING
blood sampling2
I n f u s a t e G u i d e l i n e s 1,3
The Arrow Twin Cath® may be used as a venous
sampling catheter. As with any intravenous device, the
ability to blood sample is dependent upon catheter
placement within the vein and blood flow past the
catheter.
In-vitro studies suggest the following recommended
guidelines:
1.
Two IVPB (IV piggy back) or continuous infusion
medications can be administered simultaneously
into a single vein through the separate catheter
ports.
2.
One bolus medication and one IVPB or continuous
infusion can be administered simultaneously into a
single vein through the separate catheter ports.
3.
Simultaneous administration of two bolus
medications is not recommended through the
separate catheter ports. There is clear in-vitro
evidence of medication interaction at normal
venous flow rates.
Aspiration Rates
The maximum rate of aspiration through any
indwelling catheter is dependent on the inherent
resistance to flow through the catheter itself and on the
ability of the cannulated vessel to supply a sufficient
quantity of blood.
Maximum Aspiration Rates
T h r o u g h t h e 1 8 G a . T w i n C a t h ®2
These guidelines apply to both the inactivation of one
drug by another and the formation of a precipitate.
Port
Maximum Aspiration Rate
Proximal (22 Ga.)
20ml/min.
Distal (20 Ga.)
30ml/min.
The above rates were established using a manual
syringe sampling technique. The maximum aspiration
rates listed are values just under the rates that produce
cavitation.
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BLOOD SAMPLING
BLOOD SAMPLING
The preceding aspiration rates were established using
the 18 Ga. Twin Cath®. These guidelines should also be
applied to the 16 Ga. Twin Cath®, although aspiration
rates for the 16 Ga. Twin Cath® should be somewhat
higher.
Discard Volumes
A concern of using an indwelling catheter for venous
sampling is contamination of the specimen with
catheter flush solutions.
Discard volumes were established by using heparinized
flush solutions in in-vitro and in-vivo studies. The
results were as follows:
The appearance of vacuum-induced bubbles
indicates cavitation in the syringe. Decrease force
on the syringe piston.
•
A 1cc discard volume appears to be sufficient
to clear the catheter when not sampling for
coagulation profiles.2
•
A 10cc volume of blood must be discarded
before sampling for coagulation studies when
using a heparin lock of 100 units heparin/ml.2
•
A 5cc normal saline flush used prior to drawing
the discard will reduce the discard volume to
5cc before sampling for coagulation studies
when using a heparin lock of 10 units.
•
To decrease the volume of blood wasted on
discards, batch other blood studies with
coagulation studies, drawing them first; in this
way only 1cc discard is needed prior to the
coagulation sample.
Drawing blood samples at rates faster than the
recommended rates could cause vein collapse and
difficulty in obtaining a venous sample.
No measurable increase in the amount of blood
hemolysis was noted when withdrawing samples at
the indicated rates.
Sampling Port
In an in-vitro study it was observed that contamination
of the distal port samples by proximal lumen infusates
did occur, therefore, the proximal port is best suited
for venous sampling.
Temporarily shut off distal port infusates before
sampling through the proximal port.
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BLOOD SAMPLING
BLOOD SAMPLING
OR
Suggested Sampling Technique
11. Assemble necessary equipment i.e. gloves, sterile
alcohol or betadine wipes, syringes, 2ml NSS
11. Assemble necessary equipment, i.e. gloves, sterile
flush, labeled blood collecting tubes, sterile
alcohol or betadine wipes, syringes, 2ml NSS
injection cap.
flush, labeled blood collecting tubes, sterile
12. Wash hands.
injection cap.
12. Wash hands.
13. Glove.
13. Glove.
14. Temporarily turn off distal port infusates.
14. Temporarily turn off distal port infusates.
15. Prep proximal lumen injection cap with a sterile
alcohol wipe.
15. Close slide clamp on proximal line.
16. Withdraw recommended discard volume.
16. Prep UserGard® injection cap connection site.
17. Use sampling syringe and withdraw desired
Remove injection cap.
amount of blood for laboratory studies.
17. Attach syringe, open slide clamp or withdraw
CAUTION: Do not exert excessive force on the
syringe piston such that vacuum induced bubbles
are formed.
recommended discard volume.
18. Close slide clamp, attach blood sampling syringe,
open slide clamp and withdraw desired amount of
blood for laboratory studies.
18. Resume distal infusate flow.
PRECAUTION: Do not exert excessive force on
the syringe piston such that vacuum induced
bubbles are formed.
19. Flush the proximal lumen making sure that all
blood is flushed from the injection cap. Utilize the
“locking” technique described under the Lumen
Patency Section. If unable to flush the blood from
19. Close slide clamp, attach syringe with 2cc NSS.
the cap, a cap change should be done. Make sure
10. Resume distal infusate flow.
to prep the injection cap connection before
11. Open slide clamp and irrigate proximal line clear.
removing the cap.
12. Close clamp and attach a new sterile injection cap.
10. Establish a “lock”.
13. Open slide clamp and establish a “lock”.
11. Transfer blood to appropriate blood collecting
tubes.
14. Transfer blood to appropriate collecting tubes.
OR
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CATHETER SITE CARE
CATHETER SITE CARE
catheter site care
The following guidelines are recommended to assist the
nurse in maintaining the multiple lumen peripheral
catheter insertion site.
16. A sterile dressing is applied.
17. Aseptic technique and avoidance of touch
contamination should be utilized in all phases of
11. Multiple lumen peripheral catheters should be
catheter maintenance.
changed every 72 hours. If longer placement is
18. Label catheter, dressing, IV administration sets
necessary due to limited access sites, or other
and solution appropriately.
reasons for site change deferral, the catheter’s
19. Document findings.
polyurethane material has excellent indwelling
characteristics. Reasons for deferring a catheter
Maintaining Lumen Patency
change and pertinent observations should be
There are a variety of “locking” solutions that are
utilized to maintain the patency of the multiple lumen
peripheral catheter. These solutions include normal
sterile saline (NSS) and heparinized normal saline with
varying heparin concentrations, e.g. 10 units of
heparin/ml, 100 units heparin/ml.
documented.
12. Assess the insertion site through an intact dressing
as well as the patient’s comfort at least every
8 hours.
13. Multiple lumen peripheral catheter dressings
Ten units of sodium heparin in 1ml. of normal saline
has been documented as effectively maintaining
catheter patency while not interfering clinically with
manifestations of altered clotting factors.6
should be changed according to hospital protocol,
or before if the dressing becomes soiled, wet or
loose.
4.
At the time of dressing change, inspect the site for
It is suggested that a single dose of heparin-lock
solution be used. Heparin-lock solutions are available
in prefilled syringes and in single and multi-dose vials.
erythema, drainage, induration or palpable
thrombosis. Assess the patient for pain or
tenderness at the site.
15. Upon dressing change, the site should be cleansed
with 70% isopropyl alcohol or povidone-iodine
solution and allowed to dry. If used, reapply a
topical ointment at the insertion site.
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CATHETER SITE CARE
REFERENCES
References
Locking Technique
11. Chapolini RJ. Incompatible drug infusion through
the Arrow Two-Lumen Catheter: an in-vitro
When establishing a “lock”, utilize the following
technique:
analysis. White Marsh Laboratories, Baltimore,
Maryland. April 1987. Unpublished data on file at
Inject all but 0.5cc of the locking solution; then
Arrow International, Inc.
while keeping a forward motion on the syringe
12. Chapolini RJ. The Arrow Twin Cath® catheter:
plunger, remove the needle from the cap. NEVER
COMPLETELY EMPTY THE SYRINGE.
performance as a venous sampling catheter. White
Utilizing this technique should prevent blood
Marsh Laboratories, Baltimore, Maryland.
backflow into the catheter lumen.
September 1987. Unpublished data on file at
Arrow International, Inc.
Suggested Procedure to
Establish a Lock
13. Chapolini RJ. Medication incompatibility and the
Arrow Twin Cath®: a follow-up. White Marsh
11. Wash hands.
Laboratories, Baltimore, Maryland. November
12. Prep injection cap with alcohol.
1987. Unpublished data on file at Arrow
International, Inc.
13. Inject 1cc to 2cc of flushing solution. Make sure to
14. Hanson RL, Grant AM, Majors KR. Heparin-lock
utilize the previously described technique.
maintenance with ten units of sodium heparin in
one milliliter of normal saline solution. Surgery
PRECAUTION: Because some infusates/
medications are incompatible with heparin, it
may be necessary to flush the heparin lock with a
compatible fluid such as normal sterile saline
before and after heparin is used.
Gynecology and Obstetrics. 1976;142:373-376.
15. Changing the peripheral IV dressing, tubing and
solutions. St. John’s Mercy Medical Center: Policy
and Procedure Manual. 1988;8. Revised.
10
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Page 12
REFERENCES
6.
Cole, MG. Flushing heparin locks: is saline
flushing really cost-effective? Journal of
Intravenous Nursing. 1989;12(1 supplement):
S23-S29.
7.
Conn, C. The importance of syringe size when
using implanted vascular access devices. J Vasc
Access Nurs. Winter, 1993; 3: 11-18.
8.
Giebel RA, Pauey SS, Bryant PP. t-PA therapy in
acute myocardial infarction. Journal of
Emergency Nursing. 1988;14(4):206-213.
9.
Mallory DL, O’Brien JA, Evans RG, et al. The use
of a double-lumen peripheral intravenous catheter
is more cost effective than two single lumen
intravenous catheters. Presented at the National
Meeting of the American Federation for Clinical
Research, Washington D.C., April 28 - May 1,
1989. Clin. Res. 1989; 37: 345A. Abstract.
10. Thee KG, Bednarczyk L. Two-lumen peripheral
IV catheter evaluation and overall clinical
acceptance. Journal of Intravenous Nursing.
1988;11(6):368-371.
11. Intravenous Nurses Society. Intravenous nursing
standards of practice. J Intravenous Nurs. 1990;
13(suppl.): S1-S98.
11