Central Venous Access Devices (CVADs)

Case Study The IV team nurse just completed insertion of a PICC line into R.J.'s right basilic vein. 1) What must you do before administering the IV antibiotic via the PICC line? 2) For what complications will you monitor R.J.?

1) Do not use a newly placed CVAD until tip position is verified w/ a chest x-ray. 2) Monitor for occlusion, embolism, infection, and catheter migration. A pneumothorax could be a complication of a centrally inserted catheter, but not a PICC.

Case Study: 1) What can you do to maintain patency of the PICC? 2) What will you teach R.J. about proper care of the PICC line?

1) Flush according to institutional policy—typically w/ at least 10 mL NS every 4 - 8 hrs and after each use. Use pulsatile flush technique and appropriate clamping depending on type of pressure cap used. If positive pressure cap—remove syringe before clamping. If negative or neutral pressure cap, clamp syringe while maintaining positive pressure (e.g., while instilling last mL of saline). 2) Teach the following: - Proper technique for cleansing port prior to access. - Proper flushing technique. - How to administer antibiotic. - S/S of occlusion and infection to monitor for. - Who to call if symptoms of occlusion and infection. - Importance of clamping catheter and keeping cap connection secure. - What to do if catheter is inadvertently open to air.

(Case Study) 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.?

• A peripherally inserted central catheter (PICC) is most appropriate for extended IV antibiotic therapy. • PICCs are used w/ pts who need vascular access for 1 week to 6 months but can be in place for longer periods. • Advantages of PICC over a central venous catheter are lower infection rate, fewer insertion-related complications, decreased cost, and insertion at bedside or outpatient area.

CVADs • Advantages • Disadvantages

• Advantages: - Immediate access. - Reduced venipunctures. - Decreased risk of extravasation. • Disadvantages: - Increased risk of systemic infection. - Invasive procedure. (MN) • Advantages of CVADs: Immediate access to central venous system, a reduced need for multiple venipunctures, and decreased risk of extravasation injury. • Disadvantages of CVADs: Increased risk of systemic infection and the invasiveness of procedure. Extravasation can still occur if there is displacement of or damage to device.

PICC • Advantages • Disadvantages

• Advantages: - Lower infection rate. - Fewer insertion-related complications. - Decreased cost. • Complications: - Catheter occlusion. - Phlebitis. (TN) • Advantages of PICC over a central venous catheter are lower infection rate, fewer insertion-related complications, decreased cost, and insertion at bedside or outpatient area. • Complications of PICCs include catheter occlusion and phlebitis. If phlebitis occurs, it usually appears w/in 7 - 10 days following insertion.

(TN) Nursing Management

• Catheter and insertion site asmt includes inspection of site for redness, edema, warmth, drainage, and tenderness or pain. • Observation of catheter for misplacement or slippage is important. Perform a comprehensive pain assessment, particularly noting any complaints of chest or neck discomfort, arm pain, or pain at insertion site. • Perform dressing changes and cleansing of the catheter insertion site using strict sterile technique. Institutional policies may vary. - Typical dressings include transparent semipermeable dressings or gauze and tape. If site is bleeding, a gauze dressing may be preferable; otherwise, transparent dressings are preferred. They allow observation of site w/o having to remove dressing. Transparent dressings may be left in place for up to 1 week if clean, dry, and intact. Change any dressing immediately if it becomes damp, loose, or visibly soiled. - Cleanse skin around catheter insertion site according to institution policy. A chlorhexidine-based preparation is the cleansing agent of choice. Its effects last longer than either povidone-iodine or isopropyl alcohol, offering improved killing of bacteria. When using chlorhexidine, cleansing skin w/ friction is critical to infection prevention. When applying a new dressing, area needs to be allowed to air dry completely before application for chlorhexidine to be effective. Secure lumen ports to skin above dressing site. Document date and time of dressing change and initial dressing.

Complications • Catheter occlusion

• Catheter occlusion: - Clamped or kinked catheter. - Tip against wall of vessel. - Thrombosis. - Precipitate buildup in lumen. (TN) • A CVAD can become occluded secondary to clamping or kinking catheter, tip coming in contact w/ vessel wall, thrombosis, or precipitate buildup in lumen. • Clinical manifestations of catheter occlusion include a sluggish infusion or aspiration, or being unable to infuse and/or aspirate. • Management of catheter occlusion includes following steps: - Instruct pt to change position, raise arm, and cough. - Assess for and alleviate clamping or kinking. - Flush w/ NS using a 10-mL syringe; do not force flush. - Fluoroscopy to determine cause and site. - Instillation of anticoagulant or thrombolytic agents.

CVADs • Where are they placed? • What are the 3 main types?

• Catheters placed in large blood vessels. - Subclavian vein, jugular vein • 3 main types: - Centrally inserted catheters. - Peripherally inserted central catheters. - Implanted ports. (MN) • CVADs are catheters placed in large blood vessels (e.g., subclavian vein, jugular vein) of people who require frequent or special access to vascular system. • There are 3 main types of CVADs: centrally inserted catheters, peripherally inserted central catheters (PICCs), and implanted ports. A physician may place any of these devices; a nurse w/ specialized training can insert PICCs.

Implanted Infusion Port • What does it consist of? • How is the catheter positioned?

• Central venous catheter connected to an implanted, single or double subcutaneous injection port. • Port is metal sheath w/ self-sealing silicone septum (TN) • Implanted infusion ports consist of a central venous catheter connected to an implanted, single or double subcutaneous injection port. • The catheter tip lies in desired vein and other end is connected to a port that is surgically implanted in a subcutaneous pocket on chest wall. • The port consists of a metal sheath w/ a self-sealing silicone septum.

PICC • What is it? • What are the types? • What kind of patients use it? • What arm would you not use?

• Central venous catheter inserted into a vein in the arm. • Single or multilumen, non tunneled. • For pt who need vascular access for 1 week - 6 months. • Cannot use arm for BP or blood draw. (TN) • Peripherally inserted central catheters (PICCs) are central venous catheters inserted into a vein in arm rather than a vein in neck or chest. They are inserted at or just above antecubital fossa (usually cephalic or basilic vein) and advanced to a position w/ tip ending in distal 1/3 of superior vena cava. • PICCs are single- or multiple-lumen, nontunneled, and are up to 60 cm in length w/ gauges ranging from 24 - 16. • They are used w/ pts who need vascular access for 1 week - 6 months but can be in place for longer periods. • Do not use arm w/ PICC for BP readings or blood drawing.

(TN) Nursing Management, cont.

• Change injection caps at regular intervals according to institution policy or if they are damaged from excessive punctures. Use strict sterile technique. Teach pt to turn head to opposite side of CVAD insertion site during cap change. If catheter cannot be clamped, instruct pt to lie flat in bed and perform, Valsalva maneuver whenever catheter is open to air to prevent an air embolism. • Flushing is one of most effective ways to maintain lumen patency and to prevent occlusion of CVAD. It also keeps incompatible drugs or fluids from mixing. • Use a NS solution in a syringe that has a barrel capacity of 10 mL or more to avoid excess pressure on catheter. If you feel resistance, do not apply force. This could result in a ruptured catheter or create an embolism if a thrombus is present. B/c of risk of contamination and infection, prefilled syringes or single-dose vials are preferred over multiple-dose vials. • Push-pause technique creates turbulence w/in catheter lumen, promoting removal of debris that adheres to catheter lumen. This technique involves injecting saline w/ a rapid alternating push-pause motion, instilling 1 - 2 mL w/ each push on syringe plunger. • If using a negative-pressure cap or neutral pressure cap, clamp catheter while maintaining positive pressure (e.g., while instilling last 1 mL of saline) to prevent reflux of blood back into catheter. • If a positive-pressure valve cap is present, it works to prevent reflux of blood and resultant catheter lumen occlusion. Remove syringe prior to clamping catheter in order to allow positive pressure valve to work correctly. Clamping catheter during flushing w/ this cap may actually promote blood reflux.

Nursing Management, cont.

• Change injection caps: - Have patient turn head to opposite side. - Valsalva if no clamp. • Flushing is important: - Normal saline prefilled syringe. - Use only 10 ml syringe or larger. - Flushing technique important.

Implanted Infusion Port • How are drugs injected? • Advantages • What does the care require?

• Drugs are injected thru skin into port. • Advantages: - Good for long-term therapy. - Low risk of infection. - Cosmetic discretion. • Care requires regular flushing. (TN) • Drugs are placed in port's reservoir either by a direct injection or thru injection into an already established IV line. • After being filled, reservoir slowly releases medicine into bloodstream. • Implanted ports are good for long-term therapy and have a low risk of infection. The hidden port offers pt cosmetic advantages and overall, has less maintenance than other types of CVADs. • Regular flushing is required to avoid formation of "sludge" (accumulation of clotted blood and drug precipitate) w/in the port septum.

Complications • Embolism

• Embolism: - Catheter breaking. - Dislodgement of thrombus. - Entry of air into circulation. (TN) • An embolism can occur secondary to catheter breakage, dislodgment of thrombus, and/or entry of air into circulation. • Clinical manifestations of embolism include chest pain, respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis), hypotension, and tachycardia. • Management of embolism includes the following steps: - Administer O2. - Clamp catheter. - Place pt on left side w/ head down (air emboli). - Notify physician.

Complications • Infection

• Infection: - Contamination during insertion or use. - Migration of organisms along catheter. - Immunosuppressed pt. (TN) • Catheter-related infection can occur secondary to contamination during insertion or use, migration of organisms along catheter, or immunosuppression. • Clinical manifestations of infection can be local (redness, tenderness, purulent drainage, warmth, edema) or systemic (fever, chills, malaise). • Management of infection includes the following: - Local. - Culture of drainage from site. - Warm, moist compresses. - Catheter removal if indicated. - Systemic. - Blood cultures. - Antibiotic therapy. - Antipyretic therapy. - Catheter removal if indicated.

Centrally Inserted Catheter • Where is it inserted? • What does the dacron cuff do?

• Inserted into a vein in neck, chest, or groin w/ tip resting in distal end of superior vena cava. • Nontunneled or tunneled. • Dacron cuff stabilizes catheter and decreases incidence of infection. (TN) • Centrally inserted catheters (also called central venous catheters [CVCs]) are inserted into a vein in neck or chest (subclavian or jugular) or groin (femoral) w/ tip resting in distal end of superior vena cava. • Other end of catheter is either nontunneled or tunneled thru subcutaneous tissue and exits thru a separate incision on chest or abdominal wall. • A Dacron cuff on catheter serves to stabilize catheter and may decrease incidence of infection by impeding bacteria migration along catheter beyond cuff.

Nursing Management

• Inspect catheter and insertion site. • Assess pain. • Change dressing and clean according to institution policies. • Transparent semipermeable dressing or gauze dressing. • Chlorhexidine preferred cleansing agent.

Implanted Infusion Port • How to access

• Part A: Figure depicting infusion port in place. Note self-sealing septum and flow of fluids into accessed vein. • Part B: - To access these devices, a special Huber-point needle w/ a deflected tip is used to prevent damage to rubber septum that could make port useless. - Huber-point needles are also available w/ tip at a 90º angle for longer infusions.

CVADs • What do they Permit, Allow, and Used to administer?

• Permit frequent, continuous, rapid, or intermittent administration of fluids and drugs. • Allow for giving drugs that are potentially vesicants. • Used to administer blood/blood products and parenteral nutrition. (MN) • CVADs. • Permit frequent, continuous, rapid, or intermittent administration of fluids and medications. • Allow for administration of drugs that are potential vesicants, blood and blood products, and parenteral nutrition.

Complications • Pnemothorax • Catheter migration

• Pneumothorax: - Perforation of visceral pleura. • Catheter migration: - Improper suturing. - Trauma, forceful flushing. - Spontaneous. (TN) • A pneumothorax can occur if pleura is perforated during insertion. Clinical manifestations include decreased or absent breath sounds, respiratory distress (cyanosis, dyspnea, tachypnea), chest pain, or distended unilateral chest. Management includes O2 administration, semi-Fowler's position, and chest tube insertion. • Catheter migration or displacement can also occur. Clinical manifestations would include sluggish infusion or aspiration, edema of chest or neck during infusion, pt complaint of gurgling sound in ear, dysrhythmias, or increased external catheter length. CVAD will need to be removed and replaced.

Case Study: • R.J. completes his required IV antibiotic regimen and returns to the clinic for removal of his PICC line. • Describe how you will remove the PICC line.

• Put on nonsterile gloves and remove dressing. • Don sterile gloves and mask; have patient turn head to other side. • Remove sutures if present. • Slowly and steadily withdraw catheter. If resistance is met, STOP. • If resistance is met—can apply warm compresses for 20 min and retry. If resistance continues, notify HCP. • Have pt perform Valsalva maneuver as last 5 - 10 cm of catheter is w/drawn. • Pressure should be immediately applied to site w/ sterile gauze to prevent air from entering and to control bleeding. • Inspect catheter tip to determine that it is intact. • After bleeding has stopped, apply an antiseptic ointment and sterile dressing to the site.

Removing CVADs

• Should be done according to institution policy. • Gently w/draw while pt performs Valsalva maneuver. • Apply pressure. • Ensure that catheter tip is intact. • Apply antiseptic ointment and dressing. (TN) • Removal of CVADs is done according to institution policy and nurse's scope of practice. In many agencies, nurses w/ demonstrated competency can remove PICCs and nontunneled central venous catheters. • Procedure involves removing any sutures and then gently w/drawing catheter while instructing pt to perform Valsalva maneuver as last 5 - 10 cm of catheter is w/drawn. • Pressure should be immediately applied to site w/ sterile gauze to prevent air from entering and to control bleeding. • Inspect catheter tip to determine that it is intact. • After bleeding has stopped, apply an antiseptic ointment and sterile dressing to site.

Centrally Inserted Catheter • What kinds of lumen? • Examples of long-term (tunneled) catheters.

• Single, double, triple, or quad lumen. • Examples of long-term (tunneled) catheters: - Hickman. - Groshong. (TN) • These catheters can have 1, 2, 3, or 4 lumens. • Multi-lumen catheters are useful in critically ill pt b/c each lumen can provide diff therapies simultaneously. For example, incompatible drugs infuse in separate lumens w/o mixing while a 3rd lumen provides access for blood sampling. • Specific types of long-term central catheters are Hickman catheters, which require clamps to make sure valve is closed, and Groshong catheters, which have a valve that opens as fluid is w/drawn or infused and remains closed when not in use.

CVADs • Used for? • Useful for what type of patients?

• Used for hemodynamic monitoring. • Useful for pts w/ limited peripheral vascular access or need for long-term vascular access. (MN) • CVADs. - Can provide a means to perform hemodynamic monitoring and obtain venous blood samples - Are useful w/ pts who have limited peripheral vascular access or who have a projected need for long-term vascular access.