Central Line

What is a Groshong cath? How do you flush?

Special catheter made of silicone rubber and has valve at its tip that prevents blood backflow and clotting - Flush briskly with 5 to 10 mL normal saline

describe a Triple lumen catheter

Temporary catheter placed in at bedside into either subclavian or jugular and tip threaded into the superior vena cava. Nontunneled. Temporary VAC, usually <30 days. High rate of infection with longer dwell times. Potential risk of pneumothorax with insertion

what is a PICC

Temporary long-term catheter placed percutaneously through cephalic or basilic vein by specially trained registered nurses - Catheter is threaded with a stylet or guide wire via the subclavian into the superior vena cava (tip placement) - placement must be confirmed by X-ray before use - single or dual lines - these lines are used for several weeks to months (not to exceed one year)

when and how should needleless connectors be cleaned?

consistently and thoroughly disinfected using alcohol, tincture or iodine, or chlorhexidine gluconate/alcohol combination prior to each access. the technique of using friction and a scrubbing motion is recommended and allow the needleless connector to dry completely before accessing.

if resistance is encountered when the catheter is being removed?

do not try to forcibly remove the catheter, notify the provider and discuss the appropriate interventions for successful removal

what types of fluids must be administered through central line?

exceeding 10% dextrose, ph of less than 5 or over 9

Nontunneled? Tunneled

external, internal

anti-infective central vascular access devices

shown a decrease in colonization and/or catheter-related bloodstream infections. coated or impregnated with chlorhexidine and silver sulfadiazine, minocycline and rifampin, and silver ion. should not be used in patients with allergies to silver, chlorhexidine, silver sulfadiazine, rifampin, or tetracyclines.

describe a subclavian line

single lumen catheter - Temporary catheter placed in at bedside into either subclavian or jugular and tip threaded into the superior vena cava

Biopatch

small circle patch impregnation with chlorhexidine to prevent against infections. Recomendended for use on all short term caths on patients over 2mos. Provides additional cath related blood stream infection prevention measure.

Why apply a petroleum-based ointment and a sterile dressing to the access site

to seal the skin-to-vein tract and decrease the risk of air embolus.

When is it recomended to use ETOH and Betadine (prvidone-iodine) to clean the site, and how do you use it?

use ETOH first. allow to dry. then betadine and allow to dry completly. If allergic to betadine, clean with betadine only. work in circular motion from center to outer area..

When is it recomended to use ChloraPrep to clean the site, and how do you use it?

use for all patients over 2mos. Rub back and forth using friction for 30 secs working from center to outter area.

When should you use transparent dressing to dress central lines insertion sites? How often you change?

use on all long term tunnelled caths and implanted ports! These get changed every 7 days.

when accessing the subclavian or jugular vein how is the patient positioned?

, the provider will place patient in a Trendelenburg (head down) position with a rolled towel or sheet under the shoulder of the proposed side. This position tends to distend the veins and decreases the risk for pneumothorax

Intraosseous therapy (IO)

- into the bone - this is a safe alternative to administer fluids and medications usually an emergency measure during resuscitation. Has been utilized effectively for both children and adults. Recently has regained its popularity with the adult populations having been used predominantly in the pediatric population for years. Used only when a conventional IV cannot be obtained - special large bore intraosseous needle inserted into bone marrow of distal tibia, proximal tibia, and distal femur - this is short term only!

what size syring for flushing a central line cath

ALWAYS 10!!! Never 3ml.

after the removal?

Apply pressure for a min 30 seconds, or until hemostasis. Patient remains flat for aprox 30 min after removal. Monitor for signs of complications (bleeding at the site). Usually the site is sealed within 72 hours, and the dressing may be removed. Change the site dressing every 24 hours until exit site has healed. Document the removal and patient's response in the chart.

how do you flush a hickman?

Aspirate exiting heparin - Flush with 10mL NS followed by 5 mL of 10 units heparin once a day (if not in use) - Single or dual lines

if a central line becomes disconnected?

CLAMP THE CATH

What are the differrent access types and where do they go?

Perifial- near wrist less than 1 week PICC near iner elbow. up to one year CVC subclavian long term port- above nipple long term midline on the bicep muscle, about 1/2 way 2-4 weeks

what is Cathflo Activase? Who gives? When used?

FIBRINOLYIC THERAPY!!!used to declot caths. Given by RNs, used on long term or permanent lines. It is expensive and should only be used when all other methods have been tried to re-establish flow through the cath.

After an infusion, what should be done?

Flush and heparinized.

how/when do you flush a Triple lumen catheter?

Flush each port with 5 to 10 mL NS followed by 5 mL of 10 units of heparin each port (if not in use) every 8 to 12 hours

how do you flush a subclavian line

Flush with 5 to 10 mL NS followed by 5 mL of 10 units heparin every 8 to 12 hours

How do you flush a PICC?

Flushed with 5 to 10 mL NS followed by 5 mL of 10 units of heparin every 8 to 12 hours if not in use -

before removal of an access needle from an implanted port and/or for periodic access and flushing, what flush and amount is needed?

Heparin lock solution of 100 units/mL is used to flush the implanted port

what is a Hickman Cath

Long-term (several months to years) catheter placed surgically under general anesthesia into subclavian and catheter tip threaded into superior vena cava, remaining catheter is tunneled underneath skin in chest wall with exit site just below nipple area

Epidural catheters

Physician places these catheters and administration of medications via these catheters should be upon physicians' order - continuous epidural infusions must be delivered via special electronic infusion device - These catheters are placed into the epidural space - Medications are administered via these catheters that allow for effective pain management - patients should be monitored closely - Narcan should be available

Midline catheters

Placed by specially trained registered nurses into the basilic, cephalic, or brachial vein into mid to proximal portion of upper arm (the tip of the midline does not extend beyond the axilla) - dwell time 2-4 weeks - dressing and cap changes same as central line - flushed with 3 to 10mL NS followed by 3 mL 10 units of heparin every 12 hours

how do you access implantable ports (perf or cath)

These ports are accessed using aseptic technique with Huber needles (non-coring needles)

Hemodialysis catheters

Two types - temporary and permanent - dressing same as central line - existing heparin is ALWAYS aspirated first - flushed with 1.3mL (for temporary line) and 1.5mL (permanent line) of 1000 to 5000 units heparin once a day if patient does not receive dialysis - USUALLY ONLY DIALYSIS NURSES FLUSH THESE CATHETERS!

Arteriovenous (AV) fistulas

Usually placed in the forearm - this is the process of connecting an artery to a vein - the site is cannulated and utilized during dialysis

Swan-Ganz catheters

Utilized in critical care units - are hemodynamic monitoring catheters - the lumens of the catheter are for attaching data-monitoring devices to determine cardiac output, core temperature, and hemodynamic analysis

Arterial lines

Utilized in critical care units to monitor patient's blood pressure - inserted usually by physician and sutured in place -assess site for signs of infection - maintain sterile dressing.

Steps When changing a central line dressing

Wash hands. Wear a disposable surgical mask. Remove old dressing with clean-gloved hands and discard appropriately. Change dressing using aseptic technique. Place on sterile gloves; cleanse skin per protocol . Inspect site while cleaning to observe for erythema, edema, or drainage. Also assess for pain or tenderness at the site. Notify physician if any of these complications mentioned are present. Place sterile gauze dressing or transparent dressing over insertion site. Label the dressing with date, time and your initials. Wash hands afterwards. Never use scissors!

describe the three ports on a triple lumen catheter.

White - proximal (longest) - 18 gauge lumen Blue - middle (median) - 18 gauge lumen Brown - distal (shortest) - 16 gauge lumen

Implanted ports for dialysis

a totally implanted dialysis access system became available in 2000 for dialysis clients - this consists of two titanium and stainless valves with two 12Fr. cannulae attached - these ports do not have a silicone septum or reservoir - a special needle is used to access the device and should only be done by a dialysis nurse trained in the use of these ports

why use central line therapy?

administer IV fluids that need to be diluted, rapid fluid administration, frequent blood sampling, central venous pressure monitoring. Give fluid to the chronic ill, administer incompatable drugs.

if the line becomes unocclusive?

all lines should be occlusive at all times. If it becomes occlusive (loose, damaged, or soiled) it must be changed immediately! So, sometimes you change more often to prevent infection.

take care of a cath, what to do?

asculate lungs, observe for cardiopulmonary distress, observe changes in neurological status, vital signs, check shest x rays

Vascular access devices should be flushed when and with what?

before and after each infusion with preservative-free 0.9% sodium chloride solutions.

removal of central lines

by a registered nurse. washing hand, don clean gloves, remove dressing. Open A sterile dressing tray. Apply sterile gloves. clean site aseptically and clip sutures. (if sutures are in place). The patient is supine (flat). patient must perform the Valsalva's technique to prevent air embolism while gently removing the catheter. Apply sterile dressing to the site & label the dressing with the time and date of removal. Apply pressure for a min 30 seconds, or until hemostasis.

complications from central line-

cardiac arrythemias, artery puncture, pneumothorax, air embolism, infection, thrombosis, cardiac tamponade

if a central line becomes disconnected, what do you do?

clamp the cath!!!

what to do when a culture is needed for the tip of the catheter?

clip the tip of the cath with sterile scissors and allow tip to drop into sterile container. Label, document.

to decrease the risk of occlusion, Central venous vascular access devices should be "locked" how and with how much? What do you do?

heparin locked after the completion of the final flush solution The recommended and preferred heparin lock solution is 10 units/mL. Always clean injection ports with alcohol or other antiseptic solution prior to accessing. Use friction and a scrubbing motion allowing the needleless connector to dry completely.

when are Needleless connectors removed or changed

if there is blood or debris within the needleless connector; prior to drawing blood culture sample from the catheter; and upon contamination (if it gets dirty)

state of the patient during temporary central line placement versus permanet lines?

is usually placed at the bedside with the patient awake and alert. Permanent lines are usually placed in surgery under general anesthesia

central line

is when the catheter tip is placed into the superior vena cava. This is designed for long-term therapy. A chest X-ray must be done prior to using central lines this is to confirm proper placement of the catheter tip. with the exception of Peripherally Inserted Central Catheters (PICCs), are usually placed by physicians, advanced registered nurse practitioners, or physician assistants

why does the cdc recomend the subclavian to place central line?

jugular and femoral place patient at higher risk for infection.

Subcutaneous access devices

needles are inserted into the fatty tissue below the skin offering subcutaneous infusion. Subcutaneous tissue has good absorption rates and minimal pain sensors. This also provides an effective delivery system for medications and solutions. Most common medications delivered this method are: opioids for pain management and insulin for diabetes management.

When should you use sterile gauze to dress central lines insertion sites? How often you change?

on patients who are diaphoretic, or if the site is ozzing or bleeding. Change it every 48 hours. A guaze dressing under transparent is consideered guaze.

some measure that can be used to re-establish the flow of fluid through a cath?

opening the closed clamp, repositioning the patient, flushing the catheter with normal saline to re-establish adequate fluid flow, having client to raise his/her arm above their head on the side of the central catheter

Central cath

patient is under general anesthesia. catheter is placed into subclavian and tip threaded into superior vena cava, remaining catheter is tunneled underneath skin in chest wall and port is placed under skin in chest wall, usually above nipple area. Ports are attached to catheters and sutured into place - Skin in then sutured over port - Once the incision site has healed the skin becomes the natural barrier against infection. Central implantable ports are flushed once a month (if not in use) with 10mL NS followed by 3-5 mL of 10 or 100 units of heparin.

what is a an antimicrobial cuff (Vitacuff)

placed on the central lines that are being inserted. Placed subcutaneously. has two layers: an inner layer of silicone elastomer that secures the cuff to the catheter and an outer layer of biodegradable bovine collagen that contains silver ions. These ions are released slowly and provide antimicrobial activity for 4 to 6 weeks. can be placed on single and multiple lumen catheters and also comes preattached top some long-term catheters. ACTS as a barrier to microorganisms that may occur along the subcutaneous catheter tract

peripheral catheter

placed while patient is under local anesthesia. placed into either cephalic or basilic vein and threaded into the subclavian with tip placement in the superior vena cava, remaining catheter is tunneled underneath the skin in either the forearm or upper arm and port placed under the skin in either of those areas - Ports are attached to catheters and sutured into place - Skin in then sutured over port - Once the incision site has healed the skin becomes the natural barrier against infection. Peripheral implantable ports (P.A.S. ports) are flushed once a month (if not in use) with 5 to 10 mL NS followed by 3-5 mL of 10 or 100 units of heparin.

when flushing central lines, you use what kind of pressure and why

use positive pressure to prevent blood from flowing back up into the the cath (Positive pressure is created by closing the clamp while flushing with the final milliliter (mL) of solution and keeping your finger on the plunger of the syringe until the clamp is securely closed. If you notice blood backing up into the line then positive pressure was not maintained).

what type of procedure? What do you wear?

when you remove the old dressing it is clean. Then it becomes a sterile procedure with staff wearing gowns, masks, and gloves. (Sometimes a mask is placed on the patient also.)

Hemodialysis catheters are locked how?

with heparin lock solution 1000 units/ml after each use.