Central Venous Line

Infection

- Contamination during insertion or use. - Migration of organisms along catheter - "Scrub the hub" before each use with Chlorhexidine (recommended disinfectant, Since it's been found to reduce the number of CR-BSI). - May have disinfection cap-Curo or Swabcap-remove before use and replace with new cap after use. - Assess daily the need for continued use of CVD. Signs of infection include fever, chills, swelling tenderness, redness or drainage at the insertion/exit site. Nursing interventions: - Proper sterile draping of the patient, the use of sterile gloves, gown and mask for the person inserting the central venous access device, and donning a face mask for everyone entering the area where the sterile procedure is being performed. - Proper hand hygiene, both during the insertion procedure of the central line as well as before any manipulation of a central venous access device. - Thoroughly clean injection ports with chlorhexidine (or another facility-approved antiseptic) and allow to dry prior to accessing the device. - Strict aseptic technique should be used when hanging solutions and with dressing changes. - Assess site daily for redness, drainage, swelling, or discomfort at the insertion site. To reduce the risk of infection, catheters are often coated with antimicrobial substances e.g. an antimicrobial cuff (trade name, VitaCuff) that works in conjunction with a Dacron cuff, a band around the catheter that anchors the catheter under the skin to reduce the risk of dislodgement.

Tunneled catheter - CVAD

A catheter that is tunneled through the skin and subcutaneous tissue to a central vessel; the entrance point of the catheter is distant from the entrance to the vascular system. Hickman (trade name). Open-ended catheter - require heparin flushing. Long-term use - months to years. Dacron cuff - tissue grows around this and prevents germs from traveling along the catheter site as well as anchors the catheter.

Sepsis

A severe blood infection caused by bacteria, viruses, and fungi. Extremely serious and can be life-threatening. Common manifestations include fever, chills, hypotension, tachycardia, and confusion. Nursing interventions: Follow all precautions for preventing infection. These will help prevent the progression of infection.

What are some uses and advantages of a CVL? Disadvantages?

Advantages - Allow for giving drugs that are potentially vesicants e.g. chemotherapy - Used to administer blood/blood products and total parenteral nutrition (TPN) chronic cough, sputum production, dyspnea- very hypertonic and needs large catheter - Used for hemodynamic monitoring- for blood pressure - hypo or hypervolemia. - Useful for patients with limited peripheral vascular access - Infusing medications -Long periods of time e.g. Antibiotics - Drawing blood - Less venipuncture - Multiple lumens so can infuse multiple medications, TPN, blood sampling Disadvantage - Frequent use increases chance of infections - May need to waste blood before obtaining sample.

Care of the Insertion site (CVADs)

Always use surgical asepsis (sterile technique) when changing the dressing and be sure to follow your facility's policy for specific guidelines. Change dressing when it is damp, loosened, or soiled. Change gauze dressings every 48 hours and transparent dressings 3 to 7 days or whenever they are no longer intact. A transparent semipermeable membrane dressing is often preferred as it allows easy visualization of the insertion site. Typically, gauze dressings are not recommended unless there is drainage from the site. Chlorhexidine gluconate is the preferred agent to clean the insertion site, but some use alcohol and povidone-iodine. Not recommended to use isopropyl alcohol for neonates. Povidone-iodine or chlorhexidine can be used but must be removed completely with sterile water or saline to prevent product absorption. When using alcohol and povidone-iodine, start at the catheter's insertion site and clean in a circular motion, moving from inside the circle near the catheter to the outside. Continue to enlarge the circle, being careful to continue moving outward and to avoid moving inward. Apply it for a minimum of 30 seconds and allow it to dry completely before applying povidone-iodine. When using chlorhexidine, use a back-and-forth motion. Cleanse the site for 30 seconds. With this or povidone-iodine and alcohol, be sure to cleanse the skin well beyond the dressing area. Central venous catheters have a special cap on the end where IV tubing or syringes connect into the line. This cap is called the injection or access cap. Typically, injection caps are changed every 72 to 96 hours for continuous infusions and every 7 days for intermittent infusions, most likely at the same time as a dressing change. Check your facility's policy to determine when to change the caps and, before attaching the new caps, be sure to prime them. In addition to site care and cap changes, your ongoing care includes assessing the insertion site for redness, drainage, inflammation, swelling, tenderness, and warmth.

What can you do to maintain patency of the PICC?

Aspirate. Flush with heparin.

Catheter migration

Can be improper suturing, trauma, forceful flushing or spontaneous. Leads to fluids flowing against the direction of blood flow. Nursing interventions: 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. 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.

Catheter rupture

Can occur when the catheter is broken due to excessive force with flushing or separated from the hub or port body. It could also occur when a subclavian central venous catheter gets compressed between the clavicle and the first rib, otherwise known as pinch-off syndrome. Signs of catheter rupture include fluid leaking around the site, pain or swelling during an infusion, or the inability to aspirate blood. Can be prevented by avoiding excessive force while flushing. And using the appropriate syringe size with flushing. A syringe size smaller than 10 mL could exert too much pressure, which could cause the catheter to rupture. Nursing interventions: If suspected, clamp the catheter above the break if it is visible. Also notify the provider, as the catheter may need to be repaired or replaced.

What are potential complications of CVL's?

Catheter occlusion Air Embolism Infection Sepsis Pneumothorax Catheter migration Dysrhythmias Catheter rupture

What are (CVAD) Central lines?

Catheters placed in large blood vessels such as subclavian vein, jugular vein. Example: Groshong - No need to heparinize. Hickman - need to heparinize.

Catheter occlusion

Caused by clotting inside the lumen or outside around the catheter tip that blocks the catheter's lumen. Can make it impossible to draw blood from the catheter, to flush it, or to use it for infusion. Nursing interventions: Proper catheter care and flushing the central venous access device before and after medication administration and after blood draws will help to maintain catheter patency. Advice patient to avoid excessive physical activity, but do routine movement and daily activities to prevent DVT. May need to use a thrombotic enzyme to clear the blockage. If you cannot flush the catheter, check to make sure it is not clamped or kinked. And try to: - Have the patient turn his head and cough. - Ask the patient to raise his arms over his head. - Place the patient in Trendelenburg position. - Have the patient take a deep breath. - Have the patient stand up. - Have the patient change positions in bed. It may be that the sutures securing the vascular access device are constricting the catheter. If so, obtain an order to remove the sutures and apply a stabilizing device. If the obstruction is with an implantable port, check to make sure the noncoring needle is correctly placed in the port. If it is not correctly placed, remove the needle and replace it with a correctly positioned needle.

R.J. is a 54-year-old African-American male who is admitted to the hospital with a diagnosis of infective endocarditis. R.J. will need IV access for extended antibiotic administration. What type of IV access would be most appropriate for R.J.?

Central venous access through a PICC line

What are the types of CVL's?

Centrally inserted catheters - Tunneled catheters. Non-tunneled catheters. Peripherally inserted central catheters - (PICC). Implanted ports-Port-a-cath (PAC).

The IV team nurse just completed insertion of a PICC line into R.J.'s right basilic vein. What must you do before administering the IV antibiotic via the PICC line?

Flush catheter with normal saline

Implanted Port (Port-a-cath)

Implanted under the skin. Has a metal sheath with self-sealing silicone septum, when needle removed septum reseals. Is assessed using a noncoring nonbarbed needle known as Huber needle. Has deflected points that helps in preventing injury to the septum, good for hundreds of "pokes" (very narow bevel). Accessing is a sterile technique - follow facility protocol. Advantages - good for chemotherapy. Should be flushed usually once a month to make sure it is patent. Lowers risk for infection due to natural barrier of skin, allow patients to carry on virtually all activities including bathing and swimming when it is not in use, and they do not require exit-site care. Care may requires regular flushing - even when de-accessed, need to access for flushing 1X per month. Open-ended ports require heparin flushing while valved ports do not require heparin.

PICC

Inserted into cephalic or basilica antecubital fossa and advanced to superior vena cava Single, double or triple lumens available. Note - no BP, venipunctures or grafts on that arm. Midline - exits at axilla area. Long-term use, till months. Assess site per facility protocol - Check circumference of arm in same area - Measure amount of catheter outside of body - not sutured - Check blood return before flushing -may be difficult with small lumens - May use push/pause flushing-increases turbulence in the lumen and clears the line - Always use 10 ml syringe or larger-less pressure than smaller syringe. - A typical schedule for flushing is every 12 hours when medications or fluids are not being administered. Advantages of PICC - lower infection rate, fewer insertion related complications, decrease costs since no surgery is required, inserted by specially trained RN or CRNA

Dysrhythmias

Irregular/abnormal heart rhythms. Can occur with catheter malposition or dislodgement, both during insertion later during the dwell time. A chest x-ray is therefore performed upon initial insertion to confirm the catheter tip is located in the correct area. Nursing interventions: - Confirm that radiologic results reveal accurate catheter tip location prior to initial use. - 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. - Inform the health care provider if the external catheter length has changed.

Nursing Management of CVAD

Make sure CXR is done and placement confirmed before using a CVL! Inspect catheter and insertion site Assess pain Change dressing and clean according to institution policies-sterile technique! Transparent semipermeable dressing Chlorhexidine preferred cleansing agent-use back and forth motion to clean. Flush catheter frequetly.

The IV team nurse just completed insertion of a PICC line into R.J.'s right basilic vein. For what complications will you monitor R.J.?

Occlusion, air embolism, infection, sepsis, migration, catheter rupture.

Non-tunneled catheter

Sometimes called subclavian, percutaneous, acute-care, or short-term catheters. Inserted usually into the internal jugular or subclavian vein. Femoral vein often avoided due to high risk for infection. Not commonly used for long-term care, usually less than 6 weeks. The patient should be assessed daily for need and removal when no longer needed to reduce the risk of catheter-associated bloodstream infection. Because a nontunneled catheter protrudes externally and because there is no subcutaneous tunneling, the risk for infection is greater than with other central venous access devices. Also, venipuncture directly above the lungs increases the risk of pneumothorax.

What does PICC stand for?

Peripherally inserted central catheter

Match the correct description to the nursing intervention. - Promotes maximum bactericidal effectiveness. - Prevents accidental dislodgment and catheter breakage. - Provides means to determine when the next dressing is due. - Prevents aerosolization of microorganisms over the site. Write the date, the time, and your initials on the label on the dressing. For PICC lines, coil the extension Allow the chlorhexidine to dry completely. Don mask.

Promotes maximum bactericidal effectiveness - Allow the chlorhexidine to dry completely. Prevents accidental dislodgment and catheter breakage - For PICC lines, coil the extension. Provides means to determine when the next dressing is due - Write the date, the time, and your initials on the label on the dressing. . Prevents aerosolization of microorganisms over the site - Don mask.

What is the SASH method?

Saline Administer med e.g. Antibiotic Saline Heparin (3mL/10units) - used with midline peripheral catheters

What are nursing considerations with removal of a CVL?

Should be done according to institution policy. Gently withdraw while patient performs the Valsalva maneuver. Apply pressure. Ensure that catheter tip is intact - central line usually have blue tip on them Apply antiseptic ointment and dressing.

Air Embolism

The presence of air in the veins/circulation , which can lead to cardiac arrest if it enters the heart. - Cause: catheter breaking Nursing intervention: Frequently check that the catheter is intact and patent. Always clamp catheters when accessing or changing caps!! When suspect: clamp catheter, apply oxygen, place in left trendelenberg position (traps air in right atria and moves into pulmonary system). Be sure to stay with the patient while a colleague contacts the provider.

Why is a chest x-ray done before using a newly placed CVL?

To confirm proper tip location and catheter position and that there is no pneumothorax.

Why is frequent flushing done with a CVL?

To maintain patency and prevent clogging of the catheter.

Match description A to the correct type of central vascular access device in B. A - Tunneled central venous catheter - PICC line - Implanted infusion port - Midline catheter - Percutaneous central venous catheter B - Usually located in the antecubital fossa. - Tradename is Hickman catheter. - Inserted directly through the skin and into a large vein. - Usually shorter than a PICC line. - Requires a Huber needle to access the device.

Tunneled central venous catheter - Tradename is Hickman catheter. PICC line - Usually located in the antecubital fossa. Implanted infusion port - Requires a Huber needle to access the device. Midline catheter - Usually shorter than a PICC line. Percutaneous central venous catheter - Inserted directly through the skin and into a large vein.

When flushing...

Use normal saline. Use only 10 ml syringe or larger. Use SASH method. Use push/pause flushing - increases turbulence in the lumen and clears the line. Positive pressure - flush last 0.5ml while withdrawing syringe from hub. Maintain pressure on syringe plunger while clamping tubing then disconnect the syringe.

Pneumothorax/Hemothorax

Usual manifestations: dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, and decreased breath sounds on the affected side. - Perforation of visceral pleura-with insertion - Chest x-ray after insertion before use Nursing interventions: Monitor the patient's vital signs, administer oxygen, and notify the provider. It might be necessary for the patient to have a chest tube inserted and the central line removed.

Identify the uses of a central vascular access device. (Select all that apply. a) Administering IV fluids b) Obtaining blood samples c) Infusing blood products d) Parenteral nutrition e) Enteral nutrition f) Chemotherapy g) Infusing medications h) Reducing the patient's clotting time with repeated heparinization of catheter

a) Administering IV fluids b) Obtaining blood samples c) Infusing blood products d) Parenteral nutrition f) Chemotherapy g) Infusing medications

Which of the following patients may benefit from a long-term vascular access device? (Select all that apply.) a) An adult who will receive infusions of vesicants or irritants, such as in chemotherapy for cancer treatment b) An adult who comes to the emergency room with an injured leg after a skiing accident c) An elderly, dehydrated, diabetic patient with poor peripheral circulation d) A child undergoing surgery for a tonsillectomy e) A patient who is expected to require IV antibiotics for more than 7 days for a severe respiratory infection f) A patient who will be managed at home for end-stage cancer with a continuous infusion of opioids for pain g) A patient who is having major abdominal surgery and will require TPN administration h) A pregnant patient with severe nausea and vomiting requiring fluid replacement therapy i) A patient who requires frequent long-term phlebotomy in the treatment of polycythemia.

a) An adult who will receive infusions of vesicants or irritants, such as in chemotherapy for cancer treatment. c) An elderly, dehydrated, diabetic patient with poor peripheral circulation e) A patient who is expected to require IV antibiotics for more than 7 days for a severe respiratory infection f) A patient who will be managed at home for end-stage cancer with a continuous infusion of opioids for pain g) A patient who is having major abdominal surgery and will require TPN administration i) A patient who requires frequent long-term phlebotomy in the treatment of polycythemia.

What is the primary advantage of a central venous catheter over the use of a peripheral IV? a) It can remain in place longer. b) It is unaffected by movement. c) Sterile technique is unnecessary. d) Sepsis is less likely to develop. e) There is an increased likelihood of extravasation.

a) It can remain in place longer.

Your patient has a tunneled central venous catheter. When you were cleaning the exit site, you noticed purulent drainage and redness. You look back into the patient's chart and note that he has had a fever for the last 24 hours and his white blood cell count is elevated today. The patient appears less alert, and his urine output is decreased. His medication administration record indicates that he has been receiving total parenteral nutrition. What actions should you take? (Select all that apply.) a) Notify the physician. b) Prepare to administer an antidote. c) Prepare to obtain blood cultures. d) Prepare to administer antibiotics if ordered; check allergies. e) Obtain an x-ray examination. f) Disregard, because tunneled CVCs are less likely to develop an infection than percutaneous CVCs.

a) Notify the physician. c) Prepare to obtain blood cultures. d) Prepare to administer antibiotics if ordered; check allergies.

What is the purpose of the heparin flush solution in regard to care of a vascular access device? a) To reduce the incidence of clot formation at the exit site. b) To prevent infection by promoting blood flow. c) To reduce the incidence of clot formation at the catheter tip. d) To prevent precipitate formation when medications are administered. e) To dissolve clot formation if there is an occlusion.

c) To reduce the incidence of clot formation at the catheter tip.

The nurse is obtaining a blood sample from a central line. The nurse has performed hand hygiene and applied gloves. The nurse swabs the catheter hub with an alcohol swab and a chlorhexidine swab. The nurse removes the injection cap, attaches a 10-mL syringe with normal saline, and flushes the catheter. The nurse connects an empty syringe and aspirates 5 mL of blood that is discarded appropriately. The nurse attaches a syringe and withdraws the necessary amount of blood for the sample. The nurse attaches a syringe with 10 mL of normal saline and flushes the catheter; this is followed by another syringe with 5 mL of heparin solution (100 units per mL), and flushes the catheter. The nurse replaces the cap at the end of the catheter. What complication could the patient experience because of the nurse's performance of the procedure? a) Hemorrhage from excessive heparin b) Infection c) Occlusion d) Air embolus e) Absence of complications, because the nurse performed the procedure correctly and will continue to monitor the patient

d) Air embolus

You are going to start a continuous infusion on a patient who has a central vascular access device. You are unable to flush the catheter. What actions should you take? (Select all that apply.) a) Attempt to infuse the fluids by gravity rather than by an IV pump. b) Administer a thrombolytic. c) Flush with a smaller syringe- e.g., a 1- or 3- mL syringe. d) Have the patient cough and deep breathe. e) Reposition the patient. f) Place the patient in the Trendelenburg's position. g) Raise the patient's arm. h) Forcefully flush the catheter. i) Attempt to aspirate and flush again; if unsuccessful, notify the physician. j) Make sure the tubing is kink free or clamped.

d) Have the patient cough and deep breathe. e) Reposition the patient. g) Raise the patient's arm. i) Attempt to aspirate and flush again; if unsuccessful, notify the physician. j) Make sure the tubing is kink free or clamped.