ATI: Central Venous Access Devices

What is the preferred agent to clean a central line insertion site?

Chlorhexidine gluconate -cleanse site for 30 seconds back and forth motion

General Principles for all Central Lines: Flushing

-always use a pulsing technique (push - stop - push) to help clear the line -valve-tip or closed-end valve catherters (Groshong) require only saline flushes

Complications of central lines: Infection

-common infections: Staph. aureus, yeast, and fungi Nurse: sterile technique for insertion, chlorhexidine prior to accessing device, apply new disinfection cap each time the line is accessed, strict aseptic technique when hanging solutions and drsg changes

Nursing assessment of PICCs:

-measuring pt upper arm circumference to establish baseline -measure length of external portion of catheter to baseline for later detection of catheter dislodgement -sterile drsg change 24 hrs p insertion and weekly after that -typical scheduled 12 hr flushing w/ 5 mL of heparin daily -avoid BP and venipuncture on the affected arm -educate client: no heavy lifting, keep dry and signs/symptoms

General Principles for all Central Lines: Syringe size

-only use 10 mL or larger syringes -smaller syringe has greater pressure and can rupture the catheter

General indications

-parenteral nutrition chemotherapy or other vesicant or -irritating solutions -blood products -antibiotics -IV medications or solutions (when peripheral access is limited) -central venous pressure monitoring hemodialysis

A fairly common multi-lumen catheter (MLC) configuration has three ports, commonly labeled and used as follows:

1.) distal lumen: Used for the administration of blood or other viscous fluids 2.) middle lumen: Used for parenteral nutrition 3.) proximal lumen: Used for the administration of medications or blood. It's the first hole in the catheter closest to the entry.

PICCs: After blood sampling, the line is flushed with 20 mL sterile saline. A ____ mL syringe is always used for flushing to avoid the dangers posed by increased pressures from smaller syringes.

10 mL

Complications of central lines: Catheter rupture

Signs of catheter rupture include fluid leaking around the site, pain or swelling during an infusion, or the inability to aspirate blood. Nurse: clamp the catheter above the break if it is visible. Also notify the provider, as the catheter may need to be repaired or replaced.

The recommended lumen size for blood draw:

4F or larger

Some implanted ports are considered power-injectible and can handle ___ mL/sec infusions at high pressure, which is needed during contrast enhanced CT. Special power-injection rated needles should be used to access this port.

5

The most common site for implanted port placement:

Anterior chest inferior to clavicle Less common sites: upper arm, abd, and back

At the time of insertion, a ______ _______ is done to confirm proper tip location and catheter position and to make sure that there is no pneumothorax.

Chest X-ray

Change gauze drsgs and transparent drsgs:

Gauze: q48 hrs Transparent: q3-7 days typically gauze dressings are not recommended unless drainage from site

open-ended ports require _______ flushing while valved ports no not

Heparin

Common names for central venous access devices:

Hickman, Port-A-Cath, Groshong, and Broviac

Complications of central lines: Dysrhythmia

It may occur with catheter malposition, on insertion or dislodgement Nurse: In addition to assessing heart rate and rhythm, the patient should be assessed for ear, neck, or back pain, which could also indicate catheter malposition and subsequently dysrhythmia

Implanted Port: A double-lumen port has two ________________ __________

Noncommunicating reservoirs

Complications of central lines: Pneumothorax and Hemothorax

Pneumothorax: air in the pleural space (outside the lung) Hemothorax: blood in pleural space Presents as: dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, and decreased breath sounds on affected side. Nurse: monitor VS, admin. O2, may need chest tube and removal of central line

Implanted port flushing practices:

Prior to each use, aspirate for a blood return to confirm device patency. The port must be flushed with 10 mL 0.9% sodium chloride after each use, and when not accessed monthly flushing is usually sufficient. Prior to removing the Huber needle (called deaccessing), the port should be "locked" with a heparin solution per facility protocol.

Complications of central lines: Sepsis

Severe blood infections caused by bacteria, viruses, and fungi. Exhibits as fever, chills, hypOtension, tachycardia, and confusion

Complications of central lines: Catheter lumen occlusion

Thrombosis----> thrombophlebitis presents: swollen FA, lack of blood return or sluggish flow Nurse: prevent by flushing before and after access. Thrombolytic enzyme may be ordered to clear the blockage. nonthrombotic occlusions: mechanical or impedance of fluid/medication If not flushing: -have pt turn head and cough -ask pt to raise arms over head -trendelenburg -deep breath, stand up or change position -use positive-pressure device when possible

true or false: Blood samples can be taken from any port not being used for fluid administration.

True

Complications of central lines: Pinch-off Syndrome

When a central catheter is inserted into the subclavian vein, the clavicle and rib can move together and compress the central line catheter, causing pinch-off syndrome. Warning signs include difficulty drawing blood samples and resistance to the infusion of IV fluids. Nurse: It is imperative to obtain a brisk blood return and to be able to flush the catheter easily before infusing fluids or medications through the catheter. If you cannot flush the catheter or aspirate blood, ask the patient to change the position of his arm on the catheter's side by raising it or by pulling his shoulder backward. If you are able to aspirate blood and flush the catheter after the position change, suspect pinch-off syndrome. Be sure to assess the periclavicular area near the insertion site for redness, swelling, or crepitus (a noise or vibration you can feel).

If a PICC is not placed under fluoroscopy, an __________ must verify the position of the distal tip

X-ray

Dacron cuff

a band around the catheter that anchors the catheter under the skin to reduce dislodgement risk and bacterial infection risk. Antimicrobial cuff sits proximal to this.

implanted central venous access device (IVADs) AKA Port-A-Cath

a device placed under the skin without any portion of it exiting the skin. It consists of a single or double injection port with a self-sealing silicone septum covering a metal or plastic reservoir called the body. The catheter connects the port and reservoir to a central vein, typically the superior vena cava. An implanted port can be used to administer medication including chemotherapy, to deliver fluids, and to draw blood samples.

Peripherally inserted central cetheters (PICCs):

a long central catheter that is inserted into the basilic (preferred) or cephalic vein in the arm (thus the term peripheral). The end of the catheter rests in the superior vena cava just above the right atrium. A PICC can have single or multiple lumens. PICC lines are intended for patients who require therapy for several days to months.

Complications of central lines: Catheter malposition

a result of improper technique when removing a dressing, inadequate securing of a catheter, and physical activity Nurse: Remove the dressing from the insertion site carefully to prevent inadvertent dislodgment. Also, instruct your patient about physical activity that could contribute to catheter dislodgment. If the line is pulled out, cover the site with an air-occlusive dressing. Place the patient on his left side in Trendelenburg position. Be sure to stay with the patient while a colleague contacts the provider. To prevent migration, most catheters are sutured in place. If present, the Dacron cuff also serves as an anchor. When you assess the line and the insertion site, measure the external catheter length and check for any discomfort and edema of the chest, neck, shoulder, or accessed extremity.

PICC placement can be done at the ___________ by a physician or by a specially certified RN

bedside

Complications of central lines: Air embolism

caused by accidental disconnection of central line tubing, catheter rupture, and catheter removal. presents as: dyspnea, chest pain, tachycardia, hypOtension, anxiety, nausea, dizziness, and confusion. Nurse may auscultate a "churning" noise over the pericardium - Only closed/valve-tip catheters (Groshong) can be open to air without air embolism risk. - Positive- or negative- pressure connectors determine whether clamping occurs AFTER removing syringe or WHILE pressure is maintained on the syringe plunger. Nurse: ensure catheter clamping prior to changing connections and accessing needleless connector. If suspected: 1.) clamp 2.) O2 3.) place patient on left side in Trendelenburg and stay with patient until help arrives ---This position traps the air embolism in the apex of the right atrium

Implanted port advantages:

cosmetically appealing, lowest infection risk, virtually all activities can be maintained (swimming, biking) and they do not require exit site care

Complications of central lines: Drug precipitates

incompatible medications causing chemical reaction resulting in precipitate

The tip of a central venous catheter is generally threaded into the:

internal or external jugular veins or into the lower third of the vena cava (superior or inferior) that leads to an area just above the right atrium.

Complications of central lines: Deep vein thrombosis (DVT)

related to a lack of movement Nurse: encourage ADLs

To ensure laboratory blood draw accuracy, its recommended to temporarily stop all other infusions....

until blood draw completion

IVADs: To access the port

use a noncoring, non-barbed (Huber) needle. Helps avoid septal injury by slicing through the septum Same needle access for 7 days

Most PICCs are secured with:

wound closure strips (steri-strips) or a securing device (Statlock)