Principles and Management Intravenous Lines 1

Aims To discuss Peripheral Venous Lines Planning Indications Complications Planning Good Clinical Practice 2

Aims (Cont) Central Venous Lines Golden Rules in IV Therapy Summary Indications Catheter choice Types Complications of insertion Problems Golden Rules in IV Therapy Summary 3

Peripheral Venous Lines 80% of Hospitalised patients receive Intravenous therapy at some point during their admission. Peripheral venous cannulation is the commonest method used for IV therapy They are not devoid of complications leading to increased mortality and morbidity, increased hospital stay and significant costs 4

Indications for Peripheral Venous Lines Intravenous fluid administration Correction of electrolyte imbalance Administration of blood and blood products Drug administration Prophylactic before procedures/surgery Prophylactic in unstable patients 5

Complications Local: > Position /site 44% > Phlebitis 44% > Infiltration and Extravasation 23% > IV running too slow 42% > Patient interference 41% > IV running too fast 38% 6

Complications Systemic: Circulatory overload Pharmaceutical problems Embolism Allergic reactions 7

Planning Is the key to ensuring this procedure is safe and effective for the patient. 3 distinct areas to consider: > The Patient > The Equipment > The Environment 8

Good Clinical Practice Obtain informed verbal consent Explain the procedure to the patient Patient allergies ANTT to reduce the risk of local and systemic infections Care of lines* (RCN 2010) Know national and local guidelines/policies Discuss when to change lines, labelling etc 9 9

Good Clinical Practice Use of appropriate cleansing agent – Clinelle wipes for hubs/access ports (Chloroprep for skin cleansing) Regular monitoring of vital signs VIP score Regular monitoring of access device insertion site Duration of access device use Removal of access devices Documentation Discuss re VIP scoring for cannula – not currently on meditech but being considered. At present just an IV page with insertion date, checks and removal. Care of lines – if line disconnected then must not be reconnected, labelling giving set, duration of use dependent etc Peripheral lines – 72hrs ( unless difficult to access then will need to use clinical judgement) Documentation on meditech but also discuss re Fluid Balance Charts. Policies on Grapevine 10

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Central Venous Lines A CVC is an indwelling catheter threaded into the central venous circulation; the tip will always be in either: - Superior Vena Cava - Right Atrium - Inferior Vena Cava (femoral approach) 12 12

Indications for Central Venous Lines Administration of irritant drugs/solutions and nutrition. Monitoring of CVP in acute situations Monitoring of Cardiac output Obtaining venous access when peripheral route fails or long term access 13

Catheter choice The type of central line used will depend upon the reason for insertion and the length of time the line is likely to stay in situ. Preferable to use catheters with the minimum number of lumens Use catheters impregnated with antimicrobials (with caution) Ultrasound guided positioning (NICE 2002) 14

Types of Central Venous Catheters Short-term Venous Catheters Peripherally Inserted Central Catheters (PICC) Tunnelled Catheters Implanted Venous Access Ports Short term – 1-12wks PICC – up to 12 months Tunnelled – up to 3yrs but often replaced earlier due to problems with catheters blocking etc Implanted (or portacaths) – 1000-3600 accesses 15 15

PICC Line 16

Tunnelled catheter 17

Implanted venous access ports Port-A-cath 18

Complications of insertion Incorrect positioning of catheter Haematoma Haemorrhage Arterial puncture Pneumothorax* Cardiac arrythmias Pneumothorax – trauma to pleura on insertion – reinforce importance CXR on insertion to confirm postion. Pt can have slow pleural leak post insertion – discuss close observation post procedure in case any dyspnoea 19 19

Complications Perforation (R. atrium, Pulmonary artery) Local and systemic sepsis: Colonised catheter Exit site infection/Tunnel infection Catheter related blood stream infection can be serious with substantial and directly attributable mortality/morbidity (10-35%) Discuss re statlocks/suturing lines in. Pros and cons. Discuss local policies re sending catheter tips for m,c & s post removal – routine or only if indicated. Discuss Biopatch dressings – BIOPATCH™ dressing with chlorhexidine gluconate is intended for use as a hydrophilic wound dressing that is used to absorb exudate The foam material absorbs up to eight times its own weight in fluid, while the CHG incorporated into the dressing inhibits bacterial growth under the dressing and to cover a wound caused by the use of vascular and non-vascular percutaneous medical devices such as: IV catheters, central venous lines, dialysis catheters, peripherally inserted coronary catheters, long term chest tubes, externally placed orthopaedic pins, and epidural catheters. Proven to reduce the risk of Major CRIs by 61%, and CRBSIs by 76%. 20 20

Complications (cont) Damaged catheter Catheter related thrombosis SVC syndrome (Clot occlusion of blood flow in SVC) Pinch off syndrome (rib compression of catheter) Air emboli Removal of catheter Catheter related thrombosis – reinforce importance of correct size and flushing technique – push/pause 5 mls n/saline. SVC syndrome – compression by outside structures, clot leading to increased pressure in veins to face leading to oedema (commonly caused by lesion but may be caused by clot) Pinch off syndrome – catheter compressed between 1st rib and clavicle leading to occlusion. Discuss re safe removal of central venous lines 21 21

Golden Rules of IV therapy Plan as much as possible Know national/local guidelines/policies Know how to care for venous access device and how to remove safely. Know how to use the equipment Know how to prepare drugs/solutions Know the risks/complications Obtain verbal informed consent whenever possible Know risks and complications of access devices as well as equipment, drugs etc 22 22

Golden rules of IV therapy Use ANTT Avoid unnecessary manipulation of lines/giving sets/pumps Label lines, sites clearly Regularly examine infusions while they are running Monitor patients’ vital signs Maintain good documentation Know when to seek help and from whom Reinforce re Grapevine access to BNF, Injectable medicines etc Documenting infusion checks and insertion site checks Reinforce not trusting infusion pumps 23 23

Any Questions ? 24

Summary Have discussed Peripheral Venous Lines & specific care Planning Good Clinical Practice Central Venous Lines & specific care Golden Rules in IV Therapy 25

References www.cs.cmu.edu/~pausch/news/PICCline.jpg www.codybuker.com/.../uploads/2010/02/PICC.gif www.vascularphysicians.com/images/tunneled_ca www.ivteam.com/.../uploads/2008/08/hick.jpg NICE (2002) Guidance on the use of ultrasound locating devices for placing central venous catheters Guidance No 49 RCN (2010) Standards for infusion therapy. The RCN IV Therapy Forum 3rd ed. 26