Chapter 17: Central Venous Access Devices (CVADs)

Nursing Management Continued:

----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

Complications: Catheter Occlusion

-Catheter occlusion- Clamped or kinked catheter Tip against wall of vessel Thrombosis Precipitate buildup in lumen

Removal in Detail

-Removal of CVADs is done according to institution 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the catheter while instructing the patient to perform the Valsalva maneuver as the last 5 to 10 cm of the catheter is withdrawn. -Pressure should be immediately applied 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

Case Study 2 Answer

1. Do not use a newly placed CVAD until the tip position is verified with 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 3 Answers: Question 2

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 3 Answers: Question 1

1.Flush according to institutional policy—typically with at least 10 mL normal saline every 4 to 8 hours 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).

Case Study Con't

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

Complications: Pneumothorax

A pneumothorax can occur if the Visceral pleura is perforated during insertion. Clinical manifestations include: Decreased or absent breath sounds, respiratory distress (cyanosis, dyspnea, tachypnea), chest pain, or distended unilateral chest.

CVADs Pros and Cons

Advantages: Immediate access Reduced venipunctures Decreased risk of extravasation Disadvantages: Increased risk of systemic infection Invasive procedure *Extravasation can still occur if there is displacement of or damage to the device.

PICC Pros and Cons

Advantages: Lower infection rate Fewer insertion-related complications Decreased cost Insertion at the bedside or outpatient area Complications: Catheter occlusion Phlebitis. If phlebitis occurs, it usually appears within 7 to 10 days following insertion.

Centrally Inserted Catheter

Also called central venous catheters [CVCs]) are inserted into a vein in the neck or chest (subclavian or jugular) or groin (femoral) with the tip resting in the distal end of the superior vena cava. The other end of the catheter is either nontunneled or tunneled through subcutaneous tissue and exits through a separate incision on the chest or abdominal wall. A Dacron cuff on the catheter serves to stabilize the catheter and may decrease the incidence of infection by impeding bacteria migration along the catheter beyond the cuff.

Complications: Catheter Migration

Catheter migration or displacement can also occur due to: Improper suturing Trauma, forceful flushing Spontaneous . Clinical man. : sluggish infusion or aspiration, edema of chest or neck during infusion, patient complaint of gurgling sound in ear, dysrhythmias, or increased external catheter length. **The CVAD will need to be removed and replaced.

CVADs

Catheters placed in large blood vessels Subclavian vein, jugular vein -Three main types: 1.Centrally inserted catheters 2.Peripherally inserted central catheters 3.Implanted ports

CVAD's Continued

Central venous access devices (CVADs) are catheters placed in large blood vessels (e.g., subclavian vein, jugular vein) of people who require frequent or special access to the vascular system. There are three 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 with specialized training can insert PICCs.

Implanted Infusion Port Description

Central venous catheter connected to an implanted, single or double subcutaneous injection port Port is metal sheath with self-sealing silicone septum -The catheter tip lies in the desired vein and the other end is connected to a port that is surgically implanted in a subcutaneous pocket on the chest wall.

PICC

Central venous catheter inserted into a vein in the arm rather than in neck or chest Single or multilumen, nontunneled For patients who need vascular access for 1 week to 6 months (can be in place for longer) Cannot use arm for BP or blood draw

Nursing Management Continued (Instructor's notes):

Change injection caps at regular intervals according to institution policy or if they are damaged from excessive punctures. Use strict sterile technique. Teach the patient to turn the head to the opposite side of the CVAD insertion site during cap change. If the catheter cannot be clamped, instruct the patient to 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 lumen patency and to prevent occlusion of the CVAD. 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. This could result in a ruptured catheter or create an embolism if a thrombus is present. Because of the risk of contamination and infection, prefilled syringes or single-dose vials are preferred over multiple-dose vials. The push-pause technique creates turbulence within the catheter lumen, promoting the removal of debris that adheres to the catheter lumen. This technique involves injecting the saline with a rapid alternating push-pause motion, instilling 1 to 2 mL with each push on the syringe plunger. If using a negative-pressure cap or neutral pressure cap, clamp the catheter while maintaining positive pressure (e.g., while instilling last 1 mL of saline) to prevent 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 prior to clamping the catheter in order to allow the positive pressure valve to work correctly. Clamping the catheter during flushing with this cap may actually promote blood reflux.

Nursing Management Detailed Cleaning Steps (Just look over)

Cleanse the skin around the 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 the skin with friction is critical to infection prevention. When applying a new dressing, the area needs to be allowed to air dry completely before application for chlorhexidine to be effective. Secure the lumen ports to the skin above the dressing site. Document the date and time of the dressing change and initial the dressing.

Complications: Clinical Manifestations: Occlusion

Clinical manifestations of catheter occlusion include a sluggish infusion or aspiration, or being unable to infuse and/or aspirate.

Complications: Embolism: Clin Manifestations

Clinical manifestations of embolism include chest pain, respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis), hypotension, and tachycardia.

Infection: Clinical Manifestations

Clinical manifestations of infection can be local (redness, tenderness, purulent drainage, warmth, edema) or systemic (fever, chills, malaise).

Implanted Infusion Port Con't Advantages

Drugs are injected through skin into port Advantages: Good for long-term therapy Low risk of infection Cosmetic discretion -Care requires regular flushing

Implanted Infusion Port Con't

Drugs are placed in the port's reservoir either by a direct injection or through injection into an already established IV line. After being filled, the reservoir slowly releases the medicine into the bloodstream. Implanted ports are good for long-term therapy and have a low risk of infection. The hidden port offers the patient cosmetic advantages and overall, has less maintenance than other types of CVADs. Regular flushing is required to avoid the formation of "sludge" (accumulation of clotted blood and drug precipitate) within the port septum.

Complications: Embolism

Embolism can occur secondary to: Catheter breaking Dislodgement of thrombus Entry of air into circulation

Centrally Inserted Catheter Con't

Single, double, triple, or quad lumen Examples of long-term (tunneled) catheters Hickman Groshong

CVAD's Continued

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 Allow for the administration of drugs that are potential vesicants, blood and blood products, and parenteral nutrition

Complications: Infection

Infection Contamination during insertion or use Migration of organisms along catheter Immunosuppressed patient

Nursing Management

Inspect catheter and insertion site (for redness, edema, warmth, drainage, and tenderness or pain. Assess pain: note chest or back discomfort, arm pain or pain at site Change dressing and clean according to institution policies Transparent semipermeable dressing or gauze dressing Chlorhexidine preferred cleansing agent

Pneumothorax Mgmt.

Management includes oxygen administration, semi-Fowler's position, and chest tube insertion.

Management of Complications: Occlusion

Management of catheter occlusion includes the following steps: Instruct patient to change position, raise arm, and cough Assess for and alleviate clamping or kinking Flush with normal saline using a 10-mL syringe; do not force flush Fluoroscopy to determine cause and site Instillation of anticoagulant or thrombolytic agents

Management of Complications: Embolism

Management of embolism includes the following steps: Administer oxygen Clacatheter Place patient up on left side with head down (air emboli) Notify physician

Infection: Management Steps

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

Removing CVADs

Should be done according to institution policy Gently withdraw while patient performs the Valsalva maneuver Apply pressure Ensure that catheter tip is intact Apply antiseptic ointment and dressing

Case Study 4 Answers

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 minutes and retry. If resistance continues, notify HCP. Have patient perform the Valsalva maneuver as the last 5 to 10 cm of the catheter is withdrawn. Pressure should be immediately applied 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.

Case Study 4

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.

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.?

Hickman and Groshong Catheters

Specific types of long-term central catheters are Hickman catheters, which require clamps to make sure the valve is closed, and Groshong catheters, which have a valve that opens as fluid is withdrawn or infused and remains closed when not in use.

Case Study 2

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? For what complications will you monitor R.J.?

Centrally Inserted Catheter Con't

These catheters can have one, two, three, or four lumens. Multi-lumen catheters are useful in the critically ill patient because each lumen can provide different therapies simultaneously. For example, incompatible drugs infuse in separate lumens without mixing while a third lumen provides access for blood sampling.

PICC Con't

They are inserted at or just above the antecubital fossa (usually cephalic or basilic vein) and advanced to a position with the tip ending in the distal one third of the superior vena cava. PICCs are up to 60 cm in length with gauges ranging from 24 to 16.

Nursing Management Dressings:

Typical dressings include transparent semipermeable dressings or gauze and tape. If the site is bleeding, a gauze dressing may be preferable; otherwise, transparent dressings are preferred. They allow observation of the site without having to remove the 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.

CVAD's Continued

Used for hemodynamic monitoring Useful for patients with limited peripheral vascular access or need for long-term vascular access Ex. hemodynamic monitoring and obtain venous blood samples

Case Study 3:

What can you do to maintain patency of the PICC? What will you teach R.J. about proper care of the PICC line?