Download CARE OF THE TUNNELED HEMODIALYSIS CENTRAL VENOUS

LEARNING MODULE
FOR
CARE OF THE TUNNELED HEMODIALYSIS CENTRAL VENOUS
CATHETER
POST-ENTRY LEVEL COMPETENCY FOR RNS AND LPNS
(CC 50-050)
Developed:
June 1998
Revision Date:
April 2014
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controlled and should be checked against the electronic file version prior to use.
Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 2 of 33
TABLE OF CONTENTS
Learning Objectives and Method ………………………………...
…………………………………………………….…..
References …………………………………………………….
Self Test ……………………………………………………….
Answers …………………………………………………
Proficiency Skills Checklists …………………………………….
Theory
Page
3
3
22
24
26
27
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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LEARNING OBJECTIVES & METHOD
Following the completion of this learning module, the RN or LPN will:
1. Discuss the indications for use of the tunneled hemodialysis Central Venous Catheter
(CVC).
2. Discuss the advantages of the tunneled hemodialysis CVC.
3. Discuss the components and placement of this device.
4. Discuss the nursing interventions required pre and post insertion of the line.
5. Describe the theory and procedure related to assessing patency, flushing, blood
withdrawal, instillation of lock solution, luer lock cap and dressing changes.
6. Demonstrate the ability to: assess patency, flush catheter lumens, blood withdrawal,
instillation of lock solution (alteplase or antibiotic locking solution instillation is to be
performed by an RN only), luer lock or TEGO connector cap and dressing changes.
7. Discuss complications associated with the tunneled hemodialysis CVC and nursing
actions to prevent and treat these complications.
8. Discuss required patient teaching components in relation to the tunneled hemodialysis
CVC.
In order to be deemed competent in the care of the tunneled hemodialysis CVC, the RN or
LPN must:
1. Review the Policy and Procedure & Learning Module associated with the tunneled
hemodialysis CVC.
2. Complete the self-test.
3. Practice the procedures and demonstrate skills to clinical educator, preceptor or
delegate.
4. Maintain a record of competence.
5. Conduct a yearly self-assessment of competency level and develop a plan in
conjunction with the unit manager to meet ongoing needs.
THEORY
1. The tunneled hemodialysis CVC is subcutaneously tunneled on the chest wall and the
external catheter exits on the chest usually above the nipple line near the sternal
border. The preferred site is the right internal jugular vein with the catheter tip adjusted
to the level of the caval atrial junction or into the right atrium. The catheter can also be
placed in the external jugular, subclavian or femoral vein; however, the right internal
jugular is the preferred site as:
1.1. the internal jugular permits easier catheter tip positioning in the right atrium,
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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1.2. use of subclavian vein is associated with thrombus formation and stenosis
1.3. the femoral vein is typically only used when chest wall insertion is not possible
Tunneled cuffed double-lumen central venous catheter inserted in the right internal jugular vein.
Vascular Access for Dialytic Therapies
Tordoir, Jan H.M., Comprehensive Clinical Nephrology, CHAPTER 87, 1031-1042
Copyright © 2010 Copyright © 2010, 2007, 2003, 2000 by Saunders, an imprint of Elsevier Inc.
The tunneled hemodialysis catheter contains two (dual) lumens. (pictured above).
The catheter tip design varies with each brand. The tip design will help to minimize blood
recirculation during dialysis.
The catheters are usually made of polyurethane material (please refer to manufacturers
product instructions for further information about specific catheter brands). Polyurethane is
soft and flexible but can rupture if excessive pressure is applied such as when using
syringes less than 10mL (i.e. the smaller the syringe the more pounds per square inch
pressure applied to the catheter).
Attached to the outside of the tunneled CVC is a thin band of felt material. When the
catheter is in place, this cuff sits about 3-5 cm from the exit site (under the skin in the
subcutaneous tunnel). The cuff's primary purpose is to promote fibrin growth, which helps
to anchor the catheter in place. Fibrin growth usually occurs within a few days - several
weeks of the catheter insertion. The cuff also helps to minimize bacteria from migrating
along the catheter.
Each of the catheter lumens has an in-line clamp and typically each lumen is color-coded
(red for “arterial” outflow of blood and blue for “venous” return).
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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Like other central venous access devices (CVADs), tunneled hemodialysis lines are chosen
for patients with kidney disease when long- term venous access is required and a creation
of an A/V fistula or graft has failed or is not matured for cannulation.
The tunneled CVC allows for repeated access for hemodialysis and related blood sampling
and IV administration. The CVC tip location may be in the right atrium or at the level of the
caval atrial junction. This position will maximize hemodilution and potentially decreases
venous irritation from medications known to cause thrombophlebitis when infused in
peripheral IV sites.
Nursing Practice Statements
Preinsertion Care
1. Provide and document patient teaching. Include the following: purpose, placement,
insertion procedure and post insertion care including what symptoms to report to the
nurse.
2. Blood work to be drawn as per physician or NP’s orders. Profile (platelet count), INR,
and PTT within seven days prior to the procedure
3. The patient may have clear fluids after midnight the day before the procedure and until
the procedure has been completed. Discussion will need to be had with the physician or
NP regarding adjustments to insulin or oral hypoglycemic medications. The procedures
are usually scheduled for the morning and it suggested to bring the hypoglycemic
medications to the hospital and take the medication after the procedure is completed.
4. Patients on warfarin who meet low risk criteria for arterial or venous thromboembolism
may be managed using the PPO (0400MR) Anticoagulation Pre/Post Radiology
Intervention. Patients on warfarin who do not meet low risk criteria for arterial or venous
thromboembolism may require a consult to Anticoagulation clinic or admission to
hospital for anticoagulation management.
5. Take all other medications as usual except for hypoglycemic medications and warfarin
as mentioned above.
6. Outpatients are to arrange for someone to accompany them and to drive them home
after the procedure as the patient usually receives IV conscious sedation.
Insertion and Nursing Care
The patient usually is admitted to Medical Day Unit (VGH site) or Minor Procedure (HI site).
A health history is completed, intravenous access initiated and hospital gown is provided.
The patient will then be transported to the Interventional Radiology suite - approximate time
one hour.
A radiologist in the radiology department inserts tunneled hemodialysis CVC. The
procedure takes approximately an hour and usually requires IV conscious sedation. This is
a sterile procedure (a gown, gloves and mask will be worn, the skin at the insertion site will
be cleansed with a disinfectant and sterile equipment will be used). An incision is made in
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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the chest wall usually above the nipple line and near the sternal border. This is known as
the exit site because it is where the catheter exits the body. From the exit site, the
catheter is tunneled subcutaneously to the jugular vein. Here another incision is made and
the catheter is entered into the jugular vein. This is known as the venotomy (insertion)
site.
The catheter is then advanced until the tip is in the correct location. The line is flushed with
normal saline and then instilled/locked with prescribed solution. The CVC may be stabilized
by sutures and/or by steri-strips at the exit site and at the insertion site. A gauze dressing is
placed over the insertion site and exit site for the first 24-48 hours (gauze dressing is
required if drainage and/or redness noted).
Post Insertion Nursing Care
Immediately and for the first two hours post insertion the patient should be assessed for
bleeding complications, pain and access problems. Frequent vitals and bed rest may be
ordered for an inpatient. An outpatient may be monitored in the Medical Day Unit /Minor
Procedure unit. The patient may eat and drink post procedure.
The patient's level of comfort and any abnormal sensations at the site should be assessed
post insertion and during the monitoring recovery period. Any abnormal sensations should
be reported to the physician or NP immediately. These symptoms may include pain upon
inspiration, burning or throbbing.
Care of the small incision line (venotomy site) is managed like other routine incision care;
the sutures and steri-strips (if applicable) are to be removed approximately 10-14 days post
procedure as ordered by the physician or NP. The exit site steri-strips (if applicable) are to
be removed 7-10 days post procedure. Often, an anchor suture is places in close proximity
to the exit site for up to 6 weeks and requires a physician or NP’s order for removal.
A review of the insertion procedure documentation is to be assessed and recorded on the
patient’s hemodialysis kardex. Prior to catheter use, the RN or LPN must verify that correct
catheter tip placement has been documented by the radiologist. Each time a catheter is
used it is assessed for the following:
- Catheter lumen volumes, size, integrity and patency
- Kinks
- Suture integrity
- Insertion site (presence of redness, drainage etc.)
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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All patients should be aware of safety precautions and signs and symptoms to report to the
health care professionals. Refer to the Capital Health Patient Guide- Tunneled
Hemodialysis Catheter (WQ85-1032)
Nursing Approach to Patient Teaching:
1. start teaching as early as possible, involve a family member if able;
2. assess patient’s readiness to learn;
3. assess most effective method of learning for patient (i.e., pictures, booklet,
demonstration, discussion);
4. design a teaching schedule so others may reinforce and add to what has been taught;
5. explain procedures in terms appropriate for the individual patient;
5.1. consistently evaluate effectiveness of teaching;
5.2. refer to Capital Health Patient Guide- Tunneled Hemodialysis Catheter (WQ851032) as an introduction.
Care and Maintenance
As discussed earlier there are several indications and benefits to patients with use of a
tunneled hemodialysis CVC. There are many potential complications that may also occur.
This section reviews specific complications; causes; preventative actions and management.
Occlusion/Dysfunction
Flushing of the tunneled hemodialysis CVC is required to prevent or delay catheter
occlusion related to fibrin formation or drug precipitate. This is accomplished by
withdrawing 5 mL of discard blood from each lumen to remove the locking solution
from the lumen and flushing of the catheter lumens with 10 mL of 0.9% normal saline
followed by instillation with locking solution. (The preferred locking solution is 4% sodium
citrate. Heparin; antibiotic lock, or Alteplase may be ordered by physician or NP).The
flushing and locking of the CVC is required q 48-72 hours and whenever the catheter is
accessed (i.e. for hemodialysis).
When TEGO connector is not in use positive pressure is used to prevent the backflow of
blood into the catheter, which could lead to clotting of blood in the catheter lumen and at
the tip of the catheter.
Methods to Maintain Positive Pressure
1. Close the clamp as the last 0.5mL of solution is injected (when TEGO connector not
in use).
2. Close the clamp to IV tubing (i.e. if giving antibiotics) before closing the catheter lumen
clamp (when TEGO connector not in use).
3. Post dialysis - administer blood back to patient by attaching the saline line to the arterial
bloodline and allowing the blood pump to return the blood.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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Infection
Systemic and local infections are possible complications of a tunneled hemodialysis CVC.
The most common source of infection is the catheter lumens but other potential causes
include: migration of skin flora up the catheter tract and/or CVC bifurcation, hematogenous
seeding from another site of infection, catheter related thrombus and rarely contaminated
infusate.
When performing catheter care it is important that the catheter does not touch the skin as
this increases the chance of infection from skin organisms. To decrease the risk of infection
from the catheter, aseptic-no touch technique is used at all times. Hand washing is critical
before performing any aspect of line care. Sterile gloves (for dressing changes), clean
gloves (for catheter access) and mask (both patient and nurse) are to be worn for catheter
dressing changes or anytime the catheter is to be accessed.
TEGO connectors are to be used as locking caps for hemodialysis catheters The TEGO
connector is a closed system device that potentially can reduce the risk of catheter related
infections resulting from repeat opening and manipulation of the CVC lumen(s).
The preferred skin antiseptic for hemodialysis catheters and exit site care is 2%
chlorhexidine gluconate/70% isopropyl alcohol. This is due to its rapid (30 second) and
persistent antimicrobial activity (up to 48 hours). In an effort to achieve maximal
effectiveness the solution must be applied to the skin using friction to the skin and cleaning
in a horizontal (side to side) plane extending 5cm from the catheter exit site, then cleaning
in a vertical (up and down) plane, then cleaning the skin beginning at the insertion site with
a circular motion (middle to outward) extended in a 5cm radius, for 30 seconds, with up to 2
minutes drying time.
The sterile exit site dressing is changed once a week or anytime the dressing is loose
and/or wet.
If the exit site is draining, red and/or sore, then sterile gauze and transparent dressings are
to be used. Gauze dressings are to be changed every hemodialysis treatment (48 to 72
hours) and prn. If the exit site is well healed and free of drainage/redness then transparent
exit site dressings can be used. Along with the exit site, the catheter bifurcation must be
covered with the transparent dressing. Transparent dressings are to be changed every 7
days (on hemodialysis days) or prn. TEGO connector caps are to be changes every 7 days
and prn. Luer lock caps are to be changed every 48-72 hours or if the line is accessed (i.e.
for blood sampling).
Signs and symptoms of infection may include elevated temperature (although this symptom
may be absent), elevated WBC's, site discomfort, redness, swelling and/or drainage.
These signs and symptoms must be reported to the physician or NP. The exit site is to be
swabbed for C&S. Blood cultures (via the catheter and peripheral) may be ordered prior to
initiating antibiotic therapy and a catheter change may be indicated.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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CVC related infections are associated with significant morbidity, mortality and treatment
costs. Since 2002, there have been several studies addressing the benefits of using
antibiotic and heparin lock solutions to help prevent/reduce catheter related infections.
However, relatively few clinical trials have addressed the overall efficacy and most effective
concentration of gentamicin. Therefore, gentamicin levels may need to be monitored and
resistance to gentamicin may need to be monitored when this CVC locking approach is
used.
Venous Air Embolism
To prevent venous air embolus and decrease the risk of infection, open the system only
when it is absolutely necessary. Lines must always be clamped when they are not in use.
All lines must be clamped before the system is opened.
Removal of the Tunneled CVC
Removal of the tunneled CVC is performed by a physician. Consideration may be given to
removal of the locking solution from the CVC lumens prior to removal. Blunt edge
dissection or surgical cut down to dissect the fibrosed cuff may be required. Patients should
lie flat during removal procedure. Patients are asked to perform the Valsalva maneuver, or
exhale, hold their breath and bear down while the line is removed and they may feel a slight
burning sensation as the line is dislodged from the tissue. Slight pressure is applied to both
the catheter venotomy site and catheter exit site post removal. To prevent venous air
embolism, an airtight dressing using Vaseline or betadine ointment gauze occlusive
dressing must be applied post removal to the exit site until the site has healed and forms a
scab. As well, if a cut down procedure (performed by the physician) is required to help free
the catheter from the subcutaneous tract than a suture may be inserted. The suture should
be removed in 7 days post procedure and requires a physician’s order. An airtight dressing
using a Vaseline or betadine ointment gauze dressing must be applied post removal to the
cut down site until the site has healed and forms a scab.
The RN or LPN is to assist the physician in the removal of the tunneled CVC as follows:
Position the patient in supine position.
Instruct the patient on Valsalva maneuver or if Valsalva maneuver is
contraindicated, have patient hold breath.
Hold slight pressure to the catheter exit site and venotomy site as indicated by the
physician.
Instruct patient to again perform Valsalva maneuver or hold his/her breath while
applying Vaseline or Betadine ointment gauze occlusive dressing.
Instruct patient to leave dressing in place for 72 hours.
Provide education to the patient as to the signs and symptoms of air embolism,
bleeding and to seek appropriate emergency medical attention if these or other
complications related to the removal of the CVC occur.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
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If a suture has been inserted, instruct patient to seek medical attention for removal
of the suture 7 days post procedure.
As per CC 02-008 LPN Skills, the condition of the patient may be defined as complex,
acute or predictable and the unit’s Charge RN is to assign the caregiver most appropriate
for the level of care required by the patient.to perform this skill. If the patient’s condition
changes from predictable to Complex or Acute, the Charge RN is to provide assistance
and/or take over the care of the patient as appropriate.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
Bleeding from the
catheter
 Excessive bleeding
for more than 2448 hours after
insertion is
unusual.
Page 11 of 33
POSSIBLE CAUSES
NURSING ACTIONS
PREVENTION/RATIONALE
Bleeding may occur if the
patient - Has some form of
coagulopathy.
 Is on an anti- coagulant.
 Is taking over the counter
medications which affect
platelet count.
 Has undergone a
traumatic insertion
procedure.
 Has been extremely
active post insertion.
 Use of a large bore
catheter.
 Has had heparin post
insertion or catheter
exchange. The heparin
may have been infused
systemically.
Identify the source of the bleeding (is it the
venotomy site or is the bleeding occurring within
the subcutaneous tunnel).
Thorough patient assessment to
determine the presence of
factors which may cause
bleeding post insertion (i.e.
bleeding disorders, abnormal
clotting blood levels).
If bleeding is excessive, notify the physician or
NP. The line may have to be removed and direct
pressure applied to the insertion site.
If bleeding occurs immediately post insertion at
the venotomy site, apply sterile gelfoam and
gauze (using aseptic technique) to the bleeding
site. A suture (if absent) may be required at the
site. DO NOT leave gelfoam on bleeding site
after bleeding has resolved (potential source of
infection if left on site for a prolonged period of
time).
More frequent dressing changes as well as mild
pressure may be needed to control bleeding.
The initial dressing should have gauze above the
insertion site to absorb the drainage.
If not contraindicated, attempt to sit the patient
up while applying pressure to the bleeding site.
Rationale: this will help to reduce venous
bleeding by reducing venous pressure within the
vessel.
A PTT may be ordered if the heparin has been
administered systemically.
Careful venipuncture technique
performed by a competent
clinician.
Locking solution of heparin
1000 units/mL or 4% sodium
citrate is ordered for instillation
of lumens for at least the first
three catheter access
procedures following a catheter
insertion or a catheter
exchange. Do not overfill the
catheter lumens (instil the
correct amount of anticoagulant
as per the lumen volume).
Rationale:
4% sodium citrate does not
cause systemic anticoagulation
effects as compared with
heparin. As well, there is little
evidence in the literature to
support the practice of catheter
lumen overfill as a means to
prevent lumen dysfunction.
Furthermore, attempts to locate
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Page 12 of 33
NURSING ACTIONS
PREVENTION/RATIONALE
literature refuting the use of 4%
sodium citrate or heparin 1000
units/mL for newly inserted or
exchanged catheter lumen
instillation has not been located.
Incorporation of these practices
(no overfill; 4% sodium citrate or
heparin 1000 units/mL) should
help reduce the chance of
significant interdialytic systemic
heparinization and associated
bleeding complications.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 13 of 33
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
NURSING ACTIONS
Catheter related
sepsis -- May or may
not have rise in
temperature, increased
pulse, chills, malaise,
drainage or redness
from the insertion site,
elevated white blood
cell count.
Infection present in the
catheter and blood most
commonly caused by
coagulase- negative
staphylococci,
staphylococcus aureus,
aerobic gram- negative
bacilli and candida
albicans. (Mermel, 2001)
Monitor patient for signs of infection (i.e. increased
temperature, chills).
Use aseptic technique during all
aspects of care.
Notify the physician or NP. Another topical
antibiotic or betadine ointment may be prescribed
in place of the Polysporin triple ung for the exit site
if the site is reddened and draining.
Wash hands thoroughly with
antibacterial soap or use alcohol
based hand rub (ABHR ) and wear
gloves and mask before caring for
the tunneled CVC or dressings.
Contamination of the
catheter lumens leading
to colonization of the
lumen interior is the most
common route of
infection. (Mermel, 2001)
The decision to remove
the catheter depends
upon the causative
organism, the type of
catheter and the
condition of the patient.
The physician or NP may order 2 sets of blood
samples for culture and sensitivity, one from the
line and one peripherally. If drainage is noted from
insertion site - send a swab for culture and
sensitivity.
If the tunneled CVC is removed, send catheter tip
(with an order) for Culture and Sensitivity (C & S).
Two modes of treatment prescribed by the
physician or NP -(1)
(2)
Leave catheter in place, treat with
antibiotics
Treat with an initial dose of antibiotics,
remove the catheter, insert another
tunneled central line (different site or
exchange over guidewire).
PREVENTION
Access and change dressings,
and adapters as outlined in
Nursing Policy and Procedure.
The use of an antibiotic lock
solution (example:
heparin/gentamicin solution)
Rationale:
CVC related infections are
associated with significant
morbidity, mortality and treatment
costs. Since 2002 there have been
several studies addressing the
benefits of using antibiotic and
heparin lock solutions to help
prevent/reduce catheter related
infections. Relatively few clinical
trials have addressed the overall
efficacy and most effective
concentration of gentamicin.
Therefore, if a gentamicin lock
solution is ordered, gentamicin
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electronic file version prior to use.
Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Page 14 of 33
NURSING ACTIONS
PREVENTION
levels, and resistance to
gentamicin may need to be
monitored.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
Catheter tip migration referred pain in the jaw,
ear or teeth;
- distended veins on
the side of the tunneled
central line;
- the length of the
catheter from the
insertion site is
lengthened.
- pain during infusion
or flushing.
- sluggish drip rate
during infusion.
- inability to aspirate
blood.
- dyspnea, cyanosis,
chest pain,
hypotension and
shock.
POSSIBLE CAUSES
Movement of the catheter
either internally or
externally .The catheter
may become looped, tip
may move out of the
correct location, the tip
may erode the
vasculature or
myocardium. Some
movement of the tip is
normal with changes in
the patient’s position,
however misdirected
hemodialysis treatment,
fluid infusions may lead
to cardiac tamponade,
extravasation, pleural
effusions and death.
Page 15 of 33
NURSING ACTIONS
PREVENTION
Measure the initial length of the catheter (measure
from exit site to end of catheter hub) post insertion
and document in the nursing kardex.
Medicate conditions which could
cause nausea and vomiting,
severe bouts of coughing.
Assess for signs and symptoms of catheter migration
(see signs and symptoms).
Teach patients to avoid pulling
on the catheter and to avoid any
activity that incorporates a lot of
upper body movement which
could dislodge the catheter.
Teach the patient to observe for these and notify
nurse if present.
If these are present, notify the physician or NP. An
x-ray to verify catheter tip placement may be
required.
Proper insertion technique.
**Do not attempt to reinsert**
Patients at an increased
risk include: Patients
who experience frequent
nausea and vomiting,
patients who are
physically active, patients
who have severe bouts of
coughing and patients
with left sided catheters.
A pull on the tunneled
CVC could cause
dislodgement of the
catheter.
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electronic file version prior to use.
Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
Occlusion/Dysfunctional
CVC -Inability to aspirate blood
and/or flush catheter
lumen or sluggish blood
return.
High venous and arterial
dialysis pressures during
therapy.
IV medication will not
infuse.
POSSIBLE CAUSES
Catheter lumen or
hemodialysis line
clamped.
Precipitate or clot in
hemodialysis bloodline
or CVC lumen.
Dressing or suture
placed too tightly.
Catheter tip lying
against the side of the
vessel wall.
Hemodialysis line, IV
tubing or catheter
lumen kinked.
Clamp on IV tubing
closed.
Volume depletion.
Page 16 of 33
NURSING ACTIONS
Check all tubing/ lines and tunneled hemodialysis
CVC for kinks - correct kinks if present.
PREVENTION
Verify CVC locking solution.
Check clamps to see if closed - release if closed.
Preferred locking solution is 4%
sodium citrate.
Check to see if dressing is too tight over the tunneled
central line.
Preferred locking solution is 4%
sodium citrate.
If blood return is absent, rule out positional problems
by:
-Asking the patient to deep breathe, cough and
change position
-Attach 10 ml syringe and attempt aspiration
- Assess TEGO connector for possible dysfunction.
-- If these measures are not successful, notify
physician or NP.
Rationale: There have been a
few small studies and one large
study comparing heparin 5000
units/mL to 4% sodium citrate.
These studies, for the most part,
demonstrated that citrate was
comparable to heparin in terms
of maintaining catheter patency.
Additionally, a prospective
cohort study concluded that the
use of citrate for CVC lumen
locking has equivalent or better
outcomes in terms of alteplase
use, need for CVC exchange
and access-related
hospitalizations when compared
with heparin.
Exceptions for Hemodialysis:
- If ordered, RN is to follow Hemodialysis CVC
Dysfunction Protocol
- Prior to hemodialysis, if unable to aspirate 5 mL of
discard blood when the catheter lumens are locked
with 4% sodium citrate then the RN or LPN may
push the sodium citrate into the catheter. The LPN
will notify the RN accordingly and the nephrologists
will be made aware of this at some point in the
patient’s hemodialysis treatment and the dialysis RN
(educated in care of the use of the Hemodialysis
CVC Dysfunction Protocol) will assess the patient’s
catheter for dysfunction and intervene accordingly.
Flush CVC with saline before
and after medication to prevent
clogging from drug precipitates.
Follow schedules for locking of
CVC lumens as outlined in
Policy and Procedure for
Maintaining Catheter Patency
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Page 17 of 33
NURSING ACTIONS
PREVENTION
If able to withdraw 5 mL of discard blood, draw up 10
mL of normal saline, attach syringe to catheter lumen
of the tunneled hemodialysis CVC, aspirate gently
for blood return, if blood return confirmed, inject
normal saline and attempt to aspirate again.
Use good dressing technique to
prevent kinking.
Check IV tubing and tunneled CVC for presence of
precipitate. Immediately withdraw 6-10mL of blood,
flush with 10 mL normal saline and change IV tubing.
Assess for volume depletion (low albumin, below
ideal body weight, nausea/vomiting).
Leaking or Broken
catheter -- Blood or fluid
leaking from the tunneled
CVC or signs and
symptoms of venous air
embolism.
Tear or hole in the
catheter or lumen
caused by:
Clamping the tunneled
central line with
instruments (i.e.
hemostats). Clamping
devices (as above)
should never be used
on tunneled CVC
because they may
cause tears.
Accidental cut with a
sharp instrument
during a dressing
change.
Improper dressing
change (i.e. catheter is
left exposed).
If noted -- Have patient hold breath or bear down.
Clamp the tubing between the break and the skin.
Apply occlusive tape over the hole
Notify physician or NP and coordinate catheter
repair.
Obtain catheter repair kit for physician.
Ensure dressing or suture is not
applied tightly as to occlude the
CVC.
Be certain to flush after taking
blood samples.
Do not let IV lines run dry
Never use any type of clamping
device on the CVC.
Do not use sharp instruments or
scissors during dressing
changes.
Use 10 mL syringes to prevent
too much catheter pressure
during flushing or instilling
procedures. Exception: When
using 5 mL pre-filled 4% sodium
citrate syringes (as ordered)
instil each catheter lumen with
the solution over 15 seconds so
as to prevent an increase in
catheter pressure.
Use dressing to secure the
CVC.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Page 18 of 33
NURSING ACTIONS
PREVENTION
Rupture caused by use
of a small syringe.
Fluid Leaking from the
luer lock cap/IV
connection of the
tunneled CVC or from
around the hemodialysis
bloodline.
Loose tubing
connection.
Tighten adaptor and IV tubing or dialysis lines. If
CVC was locked the catheter will have to be
accessed (withdraw 5 mL of blood), flushed (10 mL
of normal saline) and locked again (according to
physician or NP’s order).
Use leur lock connectors.
Ensure luer lock connectors are
secured to the catheter lumens
of the CVC.
Ensure hemodialysis bloodline is
secured to the catheter lumens
every 1 hour.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Deep vein thrombosis
of the subclavian vein
or internal jugular vein Swelling in the arm,
distension of the veins
of the arm and neck on
the side in which the
CVC is located. High
venous and arterial
pressure during
hemodialysis treatment
or the IV solution may
not infuse and may
have pain in the neck,
scapula, arm or ear.
Injury to the intima of the
wall of the vein.
Venous Air Embolism - Chest pain, dyspnea,
tachycardia, cyanosis,
decreased blood
pressure, nausea,
confusion
When 10-20mL of air is
trapped in the vein it is
carried quickly to the
right ventricle. Here it
blocks the flow of blood
from the ventricles into
the pulmonary arteries
thus the heart overfills.
The right ventricle
forcefully contracts in an
attempt to eject the
blood. However, this
causes the air bubble to
break into smaller air
bubbles, which cause
more obstruction and
pulmonary hypoxia.
Page 19 of 33
NURSING ACTIONS
PREVENTION
Notify the physician or NP.
Obstructed blood flow by
clot formation.
Changes in composition
of the blood.
Assess IV system, dialysis bloodlines are secure.
Clamp the hemodialysis bloodlines and catheter
lumens
Disconnect the patient from the hemodialysis
treatment and recirculate the blood.
If signs and symptoms are noted, place on the left
side with feet above the heart (this allows air to enter
the right atrium and disperse via the pulmonary
artery).
Notify the physician or NP.
Monitor vital signs.
Oxygen by mask is usually required.
Avoid use of instruments which
may puncture catheter (i.e.
hemostats, scissors, safety
pins).
Ensure hemodialysis bloodlines
are free of air and foam and that
the venous line is "in situ”
correctly.
Remove all air from IV tubing
prior to use.
When changing luer lock cap or
TEGO connectors - close clamp
of CVC. Keep the catheter
insertion site at or below the
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Pulmonary hypoxia
causes vasoconstriction
in the lung. This leads to
an even greater
workload for the right
ventricle. Eventually, left
ventricular filling is
reduced and cardiac
output drops, shock and
death rapidly occur.
May occur on insertion
and removal.
Page 20 of 33
NURSING ACTIONS
PREVENTION
level of the heart.
Stay with the patient.
Advise patient to avoid activities
which could dislodge or remove
the CVC.
Closely watch confused patients
to ensure they do not disconnect
the tubing or dislodge the
catheter.
Catheter is punctured.
Accidental removal of
catheter.
Opening of the system
during luer lock cap
change.
Air not removed from IV
tubings.
The tunneled CVC is
accidentally removed
Accidental pulling on the
catheter.
Tell the patient to call immediately for the nurse.
Teach patient to:
Place gauze over the exit site and hold in place for 20
minutes.
Avoid pulling on the catheter.
Then apply Vaseline or betadine ointment gauze and
an air tight dressing.
Not engage in activities which
could dislodge the catheter.
Call the physician or NP.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
SIGNS AND
SYMPTOMS
POSSIBLE CAUSES
Page 21 of 33
NURSING ACTIONS
PREVENTION
Assess for venous air embolism and take nursing
actions listed for this if signs are noted.
At Home, instruct patient to:
1. Hold breath or bear down as if having a bowel
movement until pressure is applied as stated
below.
2. Apply pressure with a gauze, clean face cloth or
hand over exit site and hold in place.
3. Call 911 or have someone take them to the
emergency department to be assessed.
Internal Catheter
Fracture- Partial or
complete breakage of
catheter internally,
possibly leading to
catheter embolism.
Swelling of the chest
wall, or feeling of
fullness in the chest
when IV infusing or
during hemodialysis
therapy. New chest
pain cough or
palpitations.
Mechanical friction
caused by shoulder
movements when
catheter is placed in the
subclavian vein medial
to the mid-clavicalar line
between the clavicle and
st
1 rib.
Notify the physician or NP.
Chest X-ray maybe ordered because it can
demonstrate catheter pinch off.
Correct placement in radiology.
Teach patients to avoid activities
with a lot of shoulder movement.
Avoid CVC placement in the
subclavian vein.
May be preceded by
catheter pinch off as
indicated by difficulty
aspirating blood or
infusing fluids when
patients are seated
upright.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 22 of 33
REFERENCES:
Alberta Health Services (2009). CVC: Sodium citrate 4% lock post hemodialysis policy.
Southern Alberta Renal Program.
ANNA Core Curriculum for Nephrology Nursing. (2008). Vascular access for hemodialysis.
In ANNA, American nephrology nurses association, (5th ed., pp. 748-751).
Anonymous (2011). Retrieved from:
http://www.nursingtimes.net/nursing-practice/clinical-zones/iv-therapy/avoiding-airembolism-when-removing-cvcs/5037174.article
Berns, J., S., Tokars, J., I. (2002). Preventing bacterial infections and antimicrobial
resistance in dialysis patients. American Journal of Kidney Disease, 40(5).
Bestul, M., B., VandenBussche, H., L. (2005). Antibiotic lock technique: Review of the
literature. Pharmacotherapy, 25(2), pp. 211-227.
Dogra, G., K. et al. (2002). Prevention of tunnelled hemodialysis catheter-related infections
Using catheter-restricted filling with gentamicin and citrate : A randomized controlled
study. Journal of American Society of Nephrology, 13, pp. 2133-2139.
Healthmark (2006). Citralock Product Monograph. MedXL Inc, Montreal, Canada.
Kim, S., H. (2004). Prevention of uncuffed hemodialysis catheter-related bacteremia using
an antibiotic lock technique: A prospective, randomized clinical trial. International
Society of Nephrology, 69, pp. 161-164.
Krishnasami A, Carlton D, Bimbo L et al (2002). Management of hemodialysis catheterrelated bacteremia with an adjunctive antibiotic lock solution. Kidney International,
61, pp.1136-41.
MacRae, J., Dojcinovic, I., Djurdjev, O., Jung, B., Shalansky, S., Levin, A., & Kiaii, M.
(2007). Citrate 4% versus heparin and the reduction of thrombosis study (CHARTS).
American Society of Nephrology 3: 369-374.
McIntyre, C., W. et al. (2004). Locking of tunnelled hemodialysis catheters with gentamicin
and heparin. Kidney International, 66, pp. 801-805.
Mermel L., A. et al. (2001). Guidelines for the management of intravascular catheter-related
infections. Journal of Intravenous Nursing, 24(3), pp.180-205.
Molzahan, Anita (Ed.) (2006).Contemporary Nephrology Nursing: Principles and Practice,
2nd ed. American nephrology nurses’ association, Pitman, NJ. Pp.569-572.
National Kidney Foundation. KDOQI Clinical Practice Guidelines and Clinical Practice
Recommendations for 2006 Updates: Hemodialysis Adequacy, Peritoneal Dialysis
Adequacy and VascularAccess. Am J Kidney Dis 48:S1-S322, 2006 (suppl 1).
(Return to Table of Contents)
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 23 of 33
Pierre, C., Allan, J., Hindmarsh, T., Jones, G., & Delisle, S. (2000). The effects of sodium
citrate in arterial catheters on acid-base and electrolyte measurements. Journal of
the Society of Critical Care Medicine, 28(5), pp. 1388-1392.
Registered Nurses’ Association of Ontario. (2008). Care and maintenance to reduce
vascular access complications. Retrieved January 31, 2014, from
http://rnao.org/Storage/39/3381_Care_and_Maintenance_to_Reduce_Vascular_Access_C
omplications._with_2008_Supplement.pdf
Safer Healthcare Now (2007). Getting started kit: Prevent central line infections how to
guide. Quebec Campaign.
Saxena, A., K., Panhotra, B., R., Naguib, M. (2002). Sudden irreversible sensory-neural
hearing loss in a patient with diabetes receiving amikacin as an antibiotic-heparin
lock. Pharmacotherapy, 22(1), pp. 105-108.
Solumed Product Monograph (2006). Your Preoperative Antisepsis Solutions.
www.solumed.biz.
TEGO Connector (Date?). Directions for Use. ICU Medical Inc.
Thomas et al., (2006). Recommendations for central venous catheter management in
hemodialysis patients. CANNT Journal, 16(1), pp 13-17.
Vercaigne, L.M., Sitar, D.S., Penner, S.B., et al. (2000) Antibiotic-heparin lock: in vitro
antibiotic stability combined with heparin in a central venous catheter.
Pharmacotherapy, 20, pp.394-9.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 24 of 33
Tunneled Central Venous Catheter (External)
Self Test
1.
Double lumen catheters are the most commonly used central venous catheters for
hemodialysis:
a) True
b) False
2.
If the catheter venotomy site contains a suture, how long is the suture typically left in
place:
a) 7-10 days
b) 10-14 days
c) 24-48 hours
d) Up to 6 weeks
3.
Reason(s) why the right internal jugular is the preferred site for hemodialysis
catheter insertion is:
a) the internal jugular permits easier catheter tip positioning in the left atrium
b) the use of subclavian vein is associated with thrombus formation and stenosis
c) the internal jugular permits easier catheter tip positioning in the right atrium
d) a, b and c
e) b and c
4.
At Capital Health, how often are tunneled hemodialysis catheters flushed?
a) q 48-72 hours
b) q 24-48 hours
c) whenever the hemodialysis catheter is accessed (i.e. blood sampling, medication
administration)
d) a and c
5.
6.
Which is the preferred routine locking solution to maintain CVC lumen patency?
a) heparin 5,000 units/mL
b) 4% sodium citrate
c) heparin 10,000 units/mL
d) heparin 1,000 units/mL
Name 3 ways to prevent an air embolism:
________________________________________________
________________________________________________
________________________________________________
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 25 of 33
(LM table of contents)
7.
Nursing observation of exit/insertion site includes:
____________________________________________
____________________________________________
____________________________________________
8.
Gauze dressings should be changed every ____________ to _________ hours and
prn.
9.
Transparent dressings should be changed every __________ days and prn.
10.
Match the descriptions with the correct signs/symptoms
a. Catheter occlusion
_______
inability to flush (central) catheter or
inability to withdraw blood
b. Exit site infection
_______
edema or tenderness in neck,
shoulder or arm
c. Air embolism
_______
redness, tenderness, swelling and
discharge at site
_______
SOB, chest pain, tachycardia and
cyanosis
d. Venous thrombosis
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 26 of 33
SELF TEST ANSWERS
1.
a
2.
b
3.
e
4.
d
5.
b
6.
7.
1. Ensure hemodialysis bloodlines are free of air and foam and that the venous line
is "in situ" correctly
2. When changing luer lock cap and/or when flushing the catheter - close clamp of
tunneled central line lumen.
3. Remove all air from IV tubing prior to use
1. Assess for redness/soreness/edema
2. Assess for drainage
3. Assess for catheter displacement and/or damage
8.
48 to 72 hours
9.
7 days
10.
a. Catheter occlusion
a
inability to flush (central)
catheter or inability to withdraw blood
b. Exit site infection
d
edema or tenderness in neck,
shoulder or arm
c. Air embolism
b
redness, tenderness, swelling
and discharge at site
d. Venous thrombosis
c
SOB, chest pain, tachycardia
and cyanosis
(LM table of contents)
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 27 of 33
Capital Health Proficiency Standards Skills Checklist
TITLE: MAINTAINING PATENCY – TUNNELED HEMODIALYSIS CVC
Name: ________________________
Unit: ______________________________
Evaluator: _____________________ Date: ______________________________
Critical Behaviours Performed
1. Masks (patient and nurse) and washes hands.
Yes
2. Wipes normal saline injection port with 2% chlorhexidinegluconate/70%
Isopropyl alcohol swab and uses separate swab to wipe locking solution
injection port (as applicable). Allows to air dry completely.
3. Draws up 10mL normal saline x 2 and prescribed locking solution or obtains
4% sodium citrate pre-filled syringes..
4. Applies non-sterile gloves.
5. Opens gauze around catheter lumens and places sterile 4x8 under
lumens while removes old gauze. Places sterile 4x8 on top of lumens.
5.1. Places prescribed antiseptic on 4x4. Cleans surrounding skin and
under lumens as outlined in policy. Allows to dry completely.
5.2. Removes gloves, washes hands. Applies new non sterile gloves.
5.3. Removes 4x8s from catheter lumens. Places sterile barrier under
lumens.
6. Cleans CVC lumen TEGO connector with 2% chlorhexidine gloconate/70%
Isopropyl alcohol swab(s). Allow to dry completely.
6.1. Attaches syringe by holding TEGO and rotating collar of syringe onto
TEGO until it stops (do not over tighten).
6.2. Opens the clamp and withdraws 5 mL of discard blood. Disconnects
syringe from TEGO by grasping TEGO and twisting syringe away from
TEGO until loose. Closes the lumen clamp.
6.3. Cleans CVC lumen TEGO connector as per 6 a). Allows to air dry
completely.
7. Attaches the normal saline syringe (as per step 6).
7.1. Opens the clamp, verifies blood return and flushes with 10mL of normal
saline. Disconnects syringe (as per step 6.1). Closes clamp.
8. Attaches syringe containing locking solution, opens the clamp and instils
the prescribed locking solution (as outlined in the Maintaining Catheter
Patency Procedure). Removes the syringe. Closes clamp.
Alteplase or heparin/gentamicin instillation is performed by RN only.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 28 of 33
9. Repeats steps 6-8 for other lumen.
10. Uses no touch technique throughout access procedure.
11. Wraps the catheter lumens with sterile gauze and tape.
12. Documents accordingly. Labels and dates CVC with locking solution name
and dose used for instillation.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 29 of 33
Capital Health Proficiency Standards Skills Checklist
TITLE: CHANGING THE TUNNELED HEMODIALYSIS CVC DRESSING & TEGO
CONNECTOR(S)
Name: ________________________
Unit: ______________________________
Evaluator: ________________________Date: ______________________________
Critical Behaviours Performed
Ye
s
1. Masks (patient and nurse) and washes hands.
2. Wears non-sterile gloves and carefully loosens the old dressing. Tries
to minimize pulling or tugging of the dressing from around the exit site.
3. Opens gauze around catheter lumens.
3.1. Places sterile 4x8 under catheter lumens and exit site while
removes old gauze dressing. Places sterile 4x8 on top of lumens
and exit site.
3.2. Places prescribed antiseptic on 4x4. Cleans surrounding skin and
under lumens as outlined in procedure. Allows to dry completely.
4. Removes gloves and washes hands. Sets up the sterile dressing tray;
adds supplies.
4.1. Removes top 4x8 gauze from lumens. Puts on sterile gloves.
4.2. Places sterile barrier under the lumens.
5. Scrubs exit site using friction to the skin and cleaning in a horizontal
(side to side) plane extending 5cm from the catheter exit site, then
cleaning in a vertical (up and down) plane, then cleaning the skin
beginning at the insertion site with a circular motion (middle to outward)
extended in a 5cm radius for 30 seconds, with up to 2 minutes drying
time. Allows to dry completely.
5.1. Wraps and cleans catheter bifurcation with 2% chlorhexidine
gluconate/70% Isopropyl alcohol moistened gauze. Air dry
completely before applying dressing.
6. Wraps and cleans each catheter lumens and TEGO connector with
cleansing solution moistened gauze. Removes gauze. Allows to air dry.
6.1. Ensures CVC lumen clamp is closed. Then using aseptic
technique, removes TEGO connector from CVC lumen and
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 30 of 33
Critical Behaviours Performed
Ye
s
attaches new TEGO connector to CVC lumen.
6.2. Applies a thin film of Polysporin® triple ointment to exit site (as
prescribed).
7. Applies a transparent or gauze dressing (as applicable) to cover the
catheter exit site and hub. Ensures the catheter exit site and hub are
visualized in the transparent window of the dressing. Secures the
mepore segment of the tegaderm dressing under both catheter lumens
by overlapping the mepore edges. Reinforces the mepore segment
under the catheter lumens with the reinforcement mepore strips
provided with the dressing. Applies to the catheter hub the second
mepore reinforcement strip over the top of the transparent dressing at
the hub.
7.1. Uses no touch technique throughout the procedure.
8. Wraps the catheter lumens with sterile gauze and tape.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 31 of 33
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 32 of 33
Capital Health Proficiency Standards Skills Checklist
TITLE: BLOOD WITHDRAWAL FROM A TUNNELED HEMODIALYSIS CVC
Name: ________________________
Unit: ______________________________
Evaluator: ________________________Date: ______________________________
Critical Behaviours Performed
Yes
1. Masks (patient and nurse) and washes hands.
2. Wipes normal saline injection port with 2% chlorhexidine
gluconate/70% Isopropyl alcohol swab and uses separate swab to wipe
locking solution injection port (as applicable). Allows to air dry
completely.
3. Draws up 10 mL of normal saline and prescribed locking solution or
obtains 4% sodium citrate pre-filled syringes. Applies non-sterile
gloves.
4. Opens gauze around catheter lumens and places sterile 4x8 under
lumens while removes old gauze. Places sterile 4x8 on top of lumens.
4.1. Places prescribed antiseptic on 4x4. Cleans surrounding skin and
under lumens as outlined in procedure. Allows to dry completely.
4.2. Removes gloves, washes hands. Applies new non sterile gloves.
4.3. Removes 4x8s from catheter lumens. Places sterile barrier under
lumens.
5. Cleans CVC lumen TEGO connector with 2% chlorhexidine
gluconate/70% Isopropyl alcohol swab(s). Allow to air dry completely.
5.1. Attaches syringe by holding TEGO and rotating collar of syringe
onto TEGO until it stops (do not over tighten)
5.2. Opens the clamp and withdraws 5 mL of discard blood.
Disconnects syringe from TEGO by grasping TEGO and twisting
syringe away from TEGO until loose. Closes the lumen clamp.
6. Attaches BD Vacutainer device to TEGO. Opens clamp. Inserts Blood
tube and engages device to fill blood tube. After filling complete,
removes blood tube, inverts tube as per CC 85-079 Venipuncture for
Blood Specimen/Blood Culture Collection (See related document –
Venipuncture Order of Draw). Removes BD Vacutainer device from
TEGO. Closes clamp.
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Care of the Tunneled External CVC
Learning Module
CC 50-050
Page 33 of 33
Critical Behaviours Performed
Yes
7. Cleans CVC lumen TEGO connector with 2% chlorhexidine
gluconate/70% Isopropyl alcohol swab(s). Allows to air dry completely.
8. Attaches the normal saline syringe, opens the clamp, verifies blood
return and flushes with 10 mL of saline. Disconnects syringe from
TEGO. Closes clamp.
9. Attaches syringe containing locking solution, opens the clamp and
instils the prescribed locking solution (as outlined in the Maintaining
Catheter Patency Procedure). Removes the syringe. Closes clamp.
Alteplase or antibiotic locking solution instillation is performed
by RN only.
10. Wraps the catheter lumens with sterile gauze and tape. Documents
accordingly.
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