CENTRAL VENOUS ACCESS



CENTRAL VENOUS ACCESS

To have an understanding of the placement of central venous catheters, it is important the have an understanding of the anatomy of the upper extremity venous system, the arms and the axilla. All of these structures play a role in successful placement and catheter tip location and the successful length of use known as the dwell time of the central venous catheter. The veins that are important in central venous access are the basilic vein, cephalic vein, the axillary vein, the subclavian vein, the internal and external jugular veins, the right and left innominate veins also known as the bracheocephalic veins and last the superior vena cava. As the nurse caring for patients with central venous access devices it is necessary for you to be fully aware of the anatomic position and the structures of the arm and the axilla venous system.

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CHOOSING THE VENOUS ACCESS DEVICE

The assessments to be done prior to choosing the type of device to be placed include the patient characteristics, therapy characteristics, and device characteristics.

Patient characteristics include the size and patency of the intended site. The vein must be large enough to accommodate the selected access device. Use of the smallest access in the largest vein allows for the best hemodilution of the prescribed infusate.

Patient preference for ease of self care should be considered if appropriate. The patient lifestyle requires consideration in choosing an external device or an implanted device. Consideration of activity limitations, maintenance necessities, and altered body image issues as well as the patient occupation and recreational activities need to be included in the assessment of patient characteristics.

The ability of safe care and routine management of the access device needs to be assessed before placement of any device. Fine motor movement, the ability to read and understand written instructions, emotional coping and the demands of therapy on the patient and caregiver are important considerations, particularly if the patient care will transfer to the home setting.

TYPES OF CENTRAL VENOUS ACCESS DEVICES

Temporary Central Catheter

Medically placed percutaneously through the chest wall into the jugular or subclavian vein and are used for fluid and blood administration, obtaining blood specimens, and administering medications. Catheter extension into the superior vena cava minimizes vessel irritation and sclerosis of the vessel due to infusion. Because of the volume of blood that flows through this portion of the superior vena cava the risk for complications is lessened.

Tunneled Catheters

Hickman, Broviac, and Groshong catheters are tunneled catheters. The closed-ended or Groshong type catheter is designed to prevent backflow into the catheter when it is not in use. The groshong catheter is used when low flow rates are to be infused. Fluids infuse through a slit valve on the side of the tip. When the there is no infusion the slit valve remains closed. The groshong catheter is never clamped due to the design – it would force the slit valve open.

The Hickman catheter is an open-ended catheter with silver ion impregnated cuff in the subcutaneous tract. The silver ion impregnated cuff promotes growth of a connective tissue seal. The seal reduces the risk of microbial immigration from the exit site along the catheter tract. Hickman catheters are flushed with heparin. The patient may shower or swim once the exit site is healed but the hub of the catheter must be covered.

Tunneled catheters are used for long term replacement therapy; medication administration, nutritional supplementation, and blood specimen withdraw. These catheters can remain in place for years. The catheter tip is inserted into a central vein, and advanced to the distal area of the superior vena cava. The remaining portion of the catheter is threaded subcutaneously to exit at a convenient distal site. Only physicians can discontinue a tunneled catheter.

Subcutaneously Implanted Ports

Also known as implanted ports, or port a catheters are surgically placed. Location can be arm, chest, abdomen, and back. Implanted ports are used for long term and complex IV therapy and Chemotherapy. Access to the port is by placement of a non-coring needle through the skin, into the self sealing injection port housed in a plastic or metal case. The self sealing septum can be accessed more than 2000 times. The catheter that attaches to the septum enters the superior vena cava. Once accessed the Port a catheters may remain accessed up to 7 days, and then be replaced. When not in use the catheter need only be accessed and flushed once every month. Infection risk and maintenance requirements are greatly reduced since the entire catheter is implanted.

Peripherally Inserted Central Catheter

PICC lines are inserted through a central vein through the arm and advanced to the superior vena cava. The PICC lines have fewer infection problems however they can have complications associated with bleeding, tenderness, nerve damage, cardiac arrhythmias, chest pain, catheter malposition, and catheter embolism. A problem is the PICC line tend to occlude easily. The PICC line can be inserted by trained nurses. PICC lines can be used for vesicants, antibiotics, hydration, chemotherapy, and nutritional supplementation.

PREVENTING INTRAVASCULAR CATHETER-RELATED BLOOD STREAM INFECTIONS

Catheter related infection is 2 to over 800 times higher with central vascular catheters than peripheral vascular catheters. Approximately 80,000 catheter related infections occur in the United States each year. These infections are associated with 2,400 – 20,000 deaths each year. These infections can be reduced with new products that have been introduced to central venous device catheters:

• Catheters impregnated with chlorhexidine-silver sulfadiazine or catheters impregnated with minocycline-rifampin

• Catheter hubs containing iodinated alcohol

• Chlorhexidine-impregnated sponge dressing placed at the catheter insertion site: Infection rate decreased from 5.2% to 3% for catheters in place less than 10 days.

CHANGING A CENTRAL LINE CATHETER DRESSING

EQUIPMENT

2% chlorhexidine in 70% alcohol or according to facility policy

Antimicrobial hand soap

Tape or transparent dressing

Needleless access caps, if also performing IV tubing change

Receptacle for soiled dressing

Clean gloves

Sterile gloves

Mask

PREPARATION

1. Review facility policy and procedure manual to determine protocol for skin prep.

2. Check medication administration record and patient chart for the last dressing change usually a dressing is changed every 72 to 96 hours.

3. Gather equipment

4. Identify the patient using two descriptors and explain the procedure to the patient

5. Perform hand hygiene

6. Position the patient flat on the back. Rationale: Reduces the risk of air embolism.

7. Have the patient turn their head away from the insertion site, and place a mask over the patient’s nose and mouth. Rationale: Decreases exposure to microorganisms at the site.

8. Use of mask is according to policy

PROCEDURE

1. Put on clean gloves

2. Carefully remove old dressing or tape without pulling on catheter. Remove edges toward insertion site. Rationale: This prevents stress on the insertion site.

3. Discard old dressing and gloves in proper receptacle.

4. Inspect site for loose sutures, signs of infection, inflammation, and check length of exposed catheter.

5. Remove clean gloves, perform hand hygiene and put on sterile gloves

6. Cleanse insertion site, sutures, and catheter with 2% chlorhexidine in 70% alcohol or according to facility policy.

7. Cleanse site using back and forth scrubbing motion for 30 seconds

8. Cover the site with a sterile transparent dressing.

9. Change IV tubing according to hospital policy.

a. Clamp the central line using on-line slide or squeeze clamp.

b. Using aseptic technique, change needleless access cap.

c. Prepare cap with antimicrobial swab.

d. Insert new tubing with needleless connector.

10. Label dressing and tubing with date and your initials.

11. Change dressing if it becomes loose, wet, or soiled or according to facility policy. Rationale: If it is wet, soiled or loose it is considered contaminated.

12. Discard equipment and gloves, and perform hand hygiene.

Clinical Alert

Required drying time needed in order to prevent skin breakdown as a result of chemical reaction between solutions and dressings.

Solutions Required dry time

Chlorhexidine gluconate 30 seconds

2% with alcohol

Chlorhexidine gluconate 2 minutes

Without alcohol

Povidone-iodine 2 minutes

70% isopropyl alcohol Dries quickly, kills bacteria only when first

applied. No lasting bactericidal effect; can excessively dry skin

INFUSING IV FLUIDS THROUGH A CENTRAL LINE

EQUIPMENT

Primed IV fluid administration set with needleless

Luer-Lok connector

Infusion delivery pump

Antimicrobial swabs

10 ml needleless syringe with 5 ml normal saline solution

Injection cap - positive pressure cap preferred

Clean gloves

PREPARATION

1. Verify the physician order.

2. Check the order with IV solution bag.

3. Take the equipment to the patient’s room.

4. Identify the patient using two descriptors.

5. Explain procedure to patient and provide privacy.

PROCEDURE

1. Perform hand hygiene and put on gloves

2. Hang IV solution on IV stand

3. Wipe access port antimicrobial swab and allow it to dry

4. Insert needleless cannula from saline flush syringe and unclamp lumen (if present)

5. Aspirate for a blood return, using very little force, to check for lumen patency and placement.

6. Inject saline solution slowly. 5 ml should be used to thoroughly flush the catheter. Rationale: To clear lumen of inline dilute heparin

7. Maintain positive pressure when withdrawing syringe by maintaining pressure on syringe plunger before you clamp or use a positive pressure injection cap. Rationale: This prevents aspiration of blood into lumen and decreases risk of catheter occlusion.

8. Swab access port with antimicrobial swabs

9. Insert IV tubing with Luer-Lok connector into access port. Unclamp lumen

10. Set electronic device to prescribed rate and begin infusing IV fluids.

11. Ensure central line dressing is clean and intact

12. Remove gloves and perform hand hygiene.

Clinical Alert

To minimize pressure on the catheter during injection NEVER use less than a 10 ml syringe for central lines. Smaller syringes increase pressure within the catheter.

Clinical Alert

All continuous IV infusions administered via a central line must have an electric infusion device in place.

Clinical Alert

Non-tunneled central vascular access device have the highest infection rate of all types of central vascular access devices; therefore, it is crucial that aseptic techniques be used in all aspects of catheter care.

INFUSION SITE COMPLICATIONS

SIGNS & SYMPTOMS POSSIBLE INDICATIONS

-Redness swelling at insertion site -Infiltration, hematoma, or sepsis

-Crepitus on chest -Subcutaneous emphysema that can lead to

-Respiratory distress with placement respiratory distress

of a central line -Pneumothorax

-Arm, shoulder or neck pain -Infiltration or thrombosis

-Temperature elevation -Catheter-related infection

-Fluid leaks from IV site -Hole or break in catheter

DRAWING BLOOD FROM A CENTRAL LINE CATHETER

EQUIPMENT

2 x 10 ml Luer-Lok syringes filled with sterile normal saline

3 ml Luer-Lok syringe with 3 ml heparinized saline (100 u/ml heparin)

Two 10 ml syringes or larger if needed with needleless cannula

Antimicrobial swabs

Blood tubes appropriate for tests ordered

Sterile injection cap

Clean gloves

PREPARATION

1. Check physician’s orders and MAR

2. Identify the patient using two descriptors

PROCEDURE

1. Explain procedure to the patient

2. Perform hand hygiene, put on gloves

3. If fluids are infusing through catheter, turn off the infusion for at least one minute prior to drawing blood specimens

4. Swab cap and hub with antimicrobial swabs for 30 seconds and allow to dry. Use most proximal lumen of catheter for blood draw. Rationale: Proximal port specimen will not be contaminated if fluids are infusing distally.

5. Remove cap from syringe and insert 10 ml saline filled syringe, unclamped catheter.

6. Flush catheter with 5-10 ml normal saline. Rationale: To determine patency of the catheter.

7. Clamp catheter, remove syringe and attach new 10 ml empty syringe. Unclamp catheter.

8. Withdraw 5 ml of blood from catheter slowly and then clamp catheter. Discard syringe. Rationale: To clear the catheter of fluids or medications, particularly heparin, before blood samples are obtained.

9. Discard of syringe in medical waste container

10. Again, clean injection cap with antimicrobial swabs and then insert a 10 ml syringe into cap and withdraw required amount of blood. Check lab manual for appropriate blood tube for each test. Rationale: Laboratories vary in the amount of blood they require.

11. Clamp the catheter, and withdraw syringe. Inject blood into laboratory blood tubes which have a vacuum that draws blood. Tubes should be secured upright in a wire basket. Rationale: Blood cells are easily damaged if put through needles smaller than 22 gauge, which causes hemolysis and abnormal laboratory results.

12. Dispose of syringe in medical waste container.

13. Swab cap and insert saline flush syringe, unclamp catheter.

14. Flush catheter slowly with 10 ml saline, clamp the catheter and remove syringe or maintain positive pressure on syringe plunger with your thumb while withdrawing syringe from the injection cap. Rational: This prevents blood backflow and lowers risk of catheter occlusion.

15. Again, swab cap and insert 10 ml syringe filled with 3 ml dilute heparin solution according to facility policy.

16. Unclamp catheter, gently infuse heparin solution.

17. Clamp catheter and withdraw syringe.

18. Change cap. Cap must be changed every 72 – 96 hours for continuous infusion and every 7 days for intermittent infusion. It must also be changed after each blood draw or blood administration or any time the cap is removed for a procedure.

19. Remove gloves and dispose in appropriate container and perform hand hygiene.

Clinical Alert

Do not discard any blood if drawing blood for cultures. Blood from the first draw is always used for blood cultures.

Clinical Alert

Specimens obtained from central catheter lines have been reported as inaccurate in some studies, especially coagulation studies. Heparin molecules can bind within the catheter to cause abnormal results. If lab values are significantly different from earlier values or from the normal range, assess client to determine if additional lab tests need to be drawn. In this case, draw specimens from a direct vein, if possible.

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Review Questions

Guidelines to prevent catheter-related blood stream infections include (Select all that apply)

1. Using good hygiene principles

2. Using a catheter impregnated with antibiotic agent

3. Prepare the IV site with betadine or alcohol swabs

4. Placing a mask on the patient when doing a dressing change

The physician has ordered a blood sample using a central line catheter. Which on of the following steps will be implemented after turning off the IV infusion for one minute?

1. Flush the catheter with normal saline

2. Insert a 10 ml syringe with a large bore needle and withdraw 10 ml blood and discard the sample

3. Insert a Huber needle into the port at a 90-degree angle until it meets resistance

4. After infusion is completed, irrigate the port with normal saline and remove the needle by pulling it out at a 60 degree angel

The major advantage of using positive pressure is to:

1. Ensure ease of obtaining blood samples from the IV site.

2. Maintain an accurate IV solution at the prescribed rate.

3. Maintain sterility at the junction of the IV tubing and the cap.

4. Prevent blood from being drawn back into the catheter when the flush syringed is removed.

You are preparing the site to access a Port – a – Cath. Which one of the following drying times is required when using chlorhexidine gluconate 2% with alcohol?

1. 30 seconds

2. 1 minute

3. 2 minutes

4. 3 minutes

Case Study

Mr. Bob Hoffmann is a 70 year old retired pharmacist who has returned from surgical placement of a Tunneled catheter, Groshong type. He will be started on a long term intermittent chemotherapy regimen for acute lymphocytic leukemia. His wife is a retired RN who worked in the operating room for many years.

1. Identify three advantages for inserting a tunneled catheter for his treatment.

2. His wife is very concerned about the initial care of the catheter. What explanation will you giver her?

3. The patient needs to be instructed on how to flush the catheter. What are the most important directions you should provide to him?

4. The patient needs to be instructed on how to flush the catheter. What are the most important directions you should provide to him?

BAKERSFIELD COLLEGE

NURSING PROGRAM

NURSING B26 LABORATORY

CASE STUDY: Central Line care

|Assignment |Date |Signature of Instructor |Comments |

|Case study |

|Case Study Questions | | | |

|Review questions | | | |

|Demonstration of central line | | | |

|dressing change | | | |

|Demonstration of Blood draw from| | | |

|a central line | | | |

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