Central Venous Access Devices

Central Venous Access Devices

Central venous access devices (CVADs) are catheters placed in large blood vessels (e.g., subclavian vein, jugular vein) of people who need frequent or special access to the vascular system. There are 3 main types of CVADs: centrally inserted catheters peripherally inserted central catheters (PICCs) implanted ports Advantages immediate access to the central venous system reduced need for multiple venipunctures decreased risk for extravasation injury Uses: allow for the administration of drugs that are potential vesicants (agents that can cause tissue damage) blood and blood products parenteral nutrition obtain venous blood samples projected need for long-term vascular access CVADs also can be used to inject radiopaque contrast media. disadvantages: increased risk for systemic infection invasiveness of the procedure Extravasation (leakage of fluid) can still occur if there is displacement of or damage to the device.

Midline Catheters

Midline catheters technically are peripheral catheters because they do not enter a central vein. A specially trained nurse can insert a midline catheter. A catheter can be from 3 to 8 inches long and have single or double lumens. They are inserted in the antecubital area through either the basilic or cephalic vein, often under ultrasound guidance. The basilic vein is best since it has a larger diameter. The tip rests right below the axilla, staying below the shoulder joint to reduce the risk for vein irritation from moving the shoulder. These lines can stay in place for up to 4 weeks.

Nursing Management: Central Venous Access Devices

Nursing management of CVADs includes assessment dressing changes cleansing injection cap changes maintenance of catheter patency Catheter and insertion site assessment includes inspecting the site for redness, edema, warmth, drainage, tenderness, or pain. Observing the catheter for misplacement or slippage is important. Perform a comprehensive pain assessment, particularly noting any reports of chest or neck discomfort, arm pain, or pain at the insertion site. Do not use a newly placed CVAD until the tip position is verified with a chest x-ray. Before manipulating a catheter for any reason, perform hand hygiene. Perform dressing changes and cleanse the catheter insertion site using strict sterile technique. Typical dressings include transparent semipermeable dressings or gauze and tape. If the site is bleeding, a gauze dressing may be preferable. They allow observation of the site without having to remove the dressing. Transparent dressings may be left in place for up to 1 week. Change any dressing at once if it becomes damp, loose, or soiled. A chlorhexidine-based preparation is the cleansing agent of choice. Its effects last longer than either povidone-iodine or alcohol, offering improved killing of bacteria. When using chlorhexidine, cleansing the skin with friction is critical to preventing infection. When applying a new dressing, allow the area to air dry completely. Secure the lumen ports to the skin above the dressing site. Document the date and time of the dressing change and initial the dressing. Disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter. Use an alcoholic chlorhexidine preparation, 70% alcohol, or povidone-iodine. Change injection caps at regular intervals according to facility policy, or if they have damage from excess punctures. Use strict sterile technique. Teach the patient to turn the head to the opposite side of the insertion site during cap change. If you cannot clamp the catheter, have the patient lie flat in bed and perform the Valsalva maneuver whenever the catheter is open to air to prevent an air embolism. Flushing is one of the most effective ways to maintain catheter patency. It also keeps incompatible drugs or fluids from mixing. Use a normal saline solution in a syringe that has a barrel capacity of 10 mL or more to avoid excess pressure on the catheter. If you feel resistance, do not apply force. Use the push-pause technique when flushing all catheters. Push-pause creates turbulence within the catheter lumen, promoting the removal of debris that adheres to the catheter lumen and decreasing the chance of occlusion. This technique involves injecting saline with a rapid alternating push-pause motion, instilling 1 to 2 mL with each push on the syringe plunger. If you are using a negative-pressure cap or neutral pressure cap, clamp the catheter while maintaining positive pressure while instilling the last 1 mL of saline. This prevents reflux of blood back into the catheter. If a positive-pressure valve cap is present, it works to prevent the reflux of blood and resultant catheter lumen occlusion. Remove the syringe before clamping the catheter to allow the positive pressure valve to work correctly.

Peripherally Inserted Central Catheters

Peripherally inserted central catheters (PICCs) are CVCs inserted into a vein in the arm. The basilic vein is best because of its large diameter. The cephalic, median cubital, or brachial veins are other options. Single-, double-, or triple-lumens are available. PICCs are used with patients who need vascular access for 1 week to 6 months, but they can be in place for longer periods. Advantages: lower infection rate fewer insertion-related complications decreased cost ability to insert at the bedside or in an outpatient area disadvantages: increased risk for deep vein thrombosis and phlebitis If phlebitis occurs, it usually happens within 7 to 10 days after insertion. Do not use the arm with the PICC to take a BP reading or draw blood. When the BP cuff is inflated, the PICC can touch the vein wall, increasing the risk for vein damage and thrombosis.

Embolism

Possible Cause • Catheter breaking • Dislodgment of thrombus • Entry of air into circulation Manifestations • Chest pain • Respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis) • Hypotension • Tachycardia Management • Apply O2 • Clamp catheter • Place patient on left side with head down (air emboli) • Notify provider

Catheter Occlusion

Possible Cause • Clamped or kinked catheter • Tip against wall of vessel • Thrombosis • Precipitate buildup in lumen Manifestations • Sluggish infusion or aspiration • Inability to infuse and/or aspirate Management • Have patient change position, raise arm, and cough • Assess and alleviate any clamping or kinking • Flush with normal saline using a 10-mL syringe. Do not force flush • Instill anticoagulant or thrombolytic agent

Catheter-Related Infection (Local or Systemic)

Possible Cause • Contamination during insertion or use • Migration of organisms along catheter • Immunosuppressed patient Manifestations • Local: redness, tenderness, purulent drainage, warmth, edema • Systemic: fever, chills, malaise Management Local • Culture drainage from site • Apply warm, moist compresses • Remove catheter if needed Systemic • Take blood cultures • Give antibiotic therapy • Give antipyretic therapy • Remove catheter if needed

Complications: Catheter Migration

Possible Cause • Improper suturing • Insertion site trauma • Changes in intrathoracic pressure • Forceful catheter flushing • Spontaneous Manifestations • Sluggish infusion or aspiration • Edema of chest or neck during infusion • Patient reports gurgling sound in ear • Dysrhythmias • Increased external catheter length Management • Prepare for fluoroscopy to verify position • Assist with removal and new CVAD placement

Pneumothorax

Possible Cause • Perforation of visceral pleura during insertion Manifestations • Decreased or absent breath sounds • Respiratory distress (cyanosis, dyspnea, tachypnea) • Chest pain • Distended unilateral chest Management • Apply O2 • Place in semi-Fowler's position • Prepare for chest tube insertion

CVAD Removal

Removing a CVAD is done according to agency policy and the nurse's scope of practice. In many agencies, nurses with demonstrated competency can remove PICCs and nontunneled central venous catheters. The procedure involves removing any sutures and then gently withdrawing the catheter. Have the patient perform the Valsalva maneuver as the last 5 to 10 cm of the catheter is withdrawn. Immediately apply pressure to the site with sterile gauze to prevent air from entering and to control bleeding. Inspect the catheter tip to determine that it is intact. After bleeding has stopped, apply an antiseptic ointment and sterile dressing to the site.

Centrally Inserted Catheters

The tip of centrally inserted catheters (also called central venous catheters [CVCs]) rests in the distal end of the superior vena cava near its junction with the right atrium. The other end of the catheter exits through a separate incision on the chest or abdominal wall. Non-tunneled catheters are usually placed in the subclavian or internal jugular vein, more rarely in the femoral vein. They are best for patients with short-term needs in an acute care setting. Surgically placed tunneled catheters (e.g., Hickman, Broviac, Groshong) are suitable for long-term needs. Tunneling of the catheter through subcutaneous tissue and the synthetic cuff used to anchor the catheter provide stability and decrease infection risk. After the site heals, the catheter does not need a dressing, making it easier for the patient to maintain the site at home. CVCs are available with single-, double-, or triple-lumens. Multi-lumen catheters are useful in the critically ill patient because each lumen can be used simultaneously to provide a different therapy.

Implanted Infusion Ports

consists of a surgically implanted CVC connected to a reservoir or port. The catheter tip lies in the desired vein. The port lies in a surgically created subcutaneous pocket on the upper chest or arm. It consists of a titanium or plastic reservoir covered with a self-sealing silicone septum. You access the port by using a special noncoring needle with a deflected tip. This prevents damage to the septum that could make the port useless Drugs are placed in the reservoir either by a direct injection or through injection into an established IV line. The reservoir then slowly releases the medicine into the bloodstream. Implanted ports are good for long-term therapy and have a low risk for infection. The hidden port offers the patient cosmetic advantages and overall has less maintenance than other types of CVADs.