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TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 1 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 ® TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 2 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. 1 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 3 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. 2 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 4 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 3 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 5 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. 4 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 6 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. 5 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 7 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. 6 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 8 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. 1 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 9 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 8 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 10 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. 9 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM Page 11 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 TwinCath Gdline 8/03 - PDFtmpl 8/27/03 2:42 PM 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