IV TERAPY & Central Venous Catheters

INSERTION OF PERIPHERAL IV LINE Aims 1. To gain peripheral venous access in order to: • administer fluids • administer blood products, medications and nutritional components 2. To minimise the risk of complications when initiating IV therapy through: • judicious choice of equipment • careful choice of IV site • good insertion technique • aseptic preparation of infusions

Key points 1. Only nurses who have been certified as competent in the insertion of IV cannula will perform this procedure. 2. Where the patient is less than 14 years of age, the IV cannula will be inserted by a medical practitioner. The exception will be in the case of neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer 3. In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts the assistance of a medical practitioner will be sought.

Known Complications of IV Therapy

Phlebitis • Catheter material • Catheter size Contributing factors: • Catheter material • Catheter size • Site of insertion • Skill of operator • Duration of cannula • Type of infusion • Dilution of solution • Host factors • Insertion in ED • Type of skin prep • Frequency of dressing change • Presence of infection

Infection Contributing factors: • Contaminated infusions • Inadequate skin preparation • Poor technique • Host factors

Extravasation Contributing factors • Age • Site of cannula • Type of cannula • Duration of cannula • IV drug infusions

Selection of Equipment Cannula selection 1. Select cannula based on purpose and duration of use, and age of patient. 2. Consider risk of infection and extravasation. 3. Cannulae made from polyurethanes are associated with decreased risk of phlebitis. 4. Steel needles have higher risk of extravasation and should be avoided where tissue necrosis is likely if extravasation occurs.

Skin prep Antiseptic solution - 70% isopropyl alcohol, 0.5 - 1% Chlorhexidine. Use an aqueous based alternative if there is a known allergy to alcohol

Selection of Catheter Site Choose a suitable vein. In adults, use long straight veins in an upper extremity away from the joints for catheter insertion - in preference to sites on the lower extremities. If possible avoid veins in the dominant hand and use distal veins first. Do not insert cannula on the side of mastectomy or AV shunts/Gortex. Transfer catheter inserted in a lower extremity site to an upper extremity site as soon as the latter is available. In paediatric patients, it is recommended that the cannula be inserted into the scalp, hand, or foot site in preference to a leg, arm, or ante cubital fossa site (Category II)

Reasons For Inserting Central Venous Catheters Limited vascular access Administration of highly osmotic or caustic fluids or medications Frequent administration of blood and blood products Frequent blood sampling Measurement of CVP Hemodialysis

Type of CVC Inserted Depends On Patient’s condition Anticipated length of therapy

Types Of Central Venous Catheters Nontunneled central catheters Tunneled central catheters Peripherally inserted central catheters (PICC) Implantable ports

NON-TUNNELED EXTERNAL CATHETERS 1. Polyurethane 2. Single or multiple lumens 3. Flow varies depending on size and ID 4. Temporary - requires frequent exchanges 5. Easier placement, removal and replacement

Nontunneled Central Venous Catheters Used for short-term therapy Inserted percutaneously Subclavian vein Internal jugular vein Femoral vein Has from 1 to 4 lumens or ports Usually from 6 to 8 inches in length

Can be quickly inserted Not flexible and may break Dislodged more easily Has the highest infection rate Dressing changes required using aseptic technique Unused ports must be routinely flushed with heparin solution and clamped

TUNNELED CATHETERS 1. Single or multiple lumens 2. Flow - variable 3. Long term 4. Easy access (no skin puncture) 5. Cuff - Dacron, vita Tunnel provides stability and protects against endovascular infection. Dacron cuff allows fibrous ingrowth around 6 weeks Vita cuff - oftern silver impregnated to retard infection, dissolves after 6 weeks

Tunneled catheter with cuffs

Tunneled catheter

Tunneled Central Venous Catheters Used for long term therapy Inserted surgically Small Dacron cuff sits in subcutaneous tunnel No dressing is required after cuff heals unless the patient is immunocompromised Initially sutured but removed in 7 to 10 days External portion of the cath can be repaired

Peripherally Inserted Central Catheters (PICC) Used for intermediate to long term therapy May be single or double lumen Inserted percutaneously Basalic vein Cephalic vein Threaded into the superior vena cava May be inserted by specially trained RN

PICC LINES 1. Silastic or polyurethane 2. Single or double lumen 3. Low flow 4. Short - long term 5. Easy access

Infusing or drawing blood from smaller gauged PICC may be more difficult Small gauged PICC infuse fluids slower and occlude faster Measure and document external length of PICC with each dressing change Dressing acts as a bacterial shield and helps anchor cath Unused ports must be flushed with Heparin solution and clamped

SUBCUTANEOUS PORTS 1. Single or double lumen 2. Flow - most commonly slow 3. Long term 4. Access requires needle puncture

SUBCUTANEOUS PORTS 5. Less maintenance 6. Activity is unlimited after site heals 7. Cosmetically more appealing 8. Concealed pocket retards infection (?)

Minimizes infection Huber needle must be used to access port Must always confirm needle placement before med administration Transparent dressing covers Huber needle and port Unused port is flushed every 28 days with Heparin solution

SUBCLAVIAN VEIN COMPLICATIONS STENOSIS THROMBOSI PINCH OFF SYNDROME Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)

ADVANTAGES OF THE RIGHT IJ 1. Larger 2. More superficial 3. Further from the lung 4. More direct route to the heart 5. Acute and chronic complications are reduced

CENTRAL VENOUS CATHETER PLACEMENT 1. Prep 2. Access 3. +/- Tunnel 4. Secure

PREP Alcohol scrub to remove surface oils Chlorhexidine scrub Betadine prep (allow to dry) Ioban dressing and drapes Maximum Sterile Barrier - Surgical hats, gowns, masks & gloves 3 - 5 min. surgical scrub Antibiotics (controversial) 30-60 min. prior Cefazolin (Kefzol, Ancef) 1 gm IV or Gentamycin 80 mg IV

General Nursing Care Of Patient With CVC Always follow the institution’s policy and procedure Before insertion, lines are initially flushed with saline During percutaneous insertion of CVC in the subclavian or jugular, place patient in Trendlenberg or have him perform Valsalva maneuver

After insertion, an occlusive gauze or transparent dressing is applied Blood is aspirated through all lumens to verify patency Chest xray must be performed before use Each lumen of the cath is secured with a Leur-lok cap or CLC 2000 device

Use only needless system to access ports Infusing devices are used for all infusions TPN is administered exclusively through a dedicated line and port. Catheters must be clamped when removing the cap and when not in use

Flushing of lines Each lumen is treated as a separate cath Injection caps are vigorously cleaned with alcohol Use 10cc or larger syringe for administration of meds or flush Turbulent flush technique is recommended

For med administration, use SAS method If port is not to be maintained with a continuous infusion, end with Heparin flush solution Peds 10kg> and adults – 100 units Heparin/ml with preservatives Neonates and peds <10kg – 10 units Heparin/ml without preservatives For specific amounts see procedure Clamp cath while infusing last ½ cc of flush If CLC 2000 used, do not clamp cath until syringe disconnected

Site assessment and determination of external cath length is performed and documented with each dressing change Tubings are changed per protocol – 72hrs Caps and connections are changed per protocol – 3-7 days

Dressing changes per protocol Use sterile technique Change when damp, soiled or loosened Change every 7 days if transparent Change every other day if gauze is used Clean skin around insertion site with alcohol in a circular motion. Also clean cath with alcohol

Use antmicrobial disk if indicated Form a loop of the tubing or cath outside the dressing and anchor securely with tape Label site with date, time and initials Document dressing change, condition of site and length of external cath when appropriate

For drawing blood specimen Discard initial sample of blood Collect specimen Flush with 10cc saline Flush with Heparin solution if indicated

Monitor for complications Infection Phlebitis Septicemia or pyrogenic reaction Air embolism Thrombosis/occlusion Extravasation Damaged cath

COMPLICATIONS 1. Acute Procedural 2. Sub-acute Infection 3. Chronic Catheter fragmentation Non-function Tunnel provides stability and protects against endovascular infection. Dacron cuff allows fibrous ingrowth around 6 weeks Vita cuff - oftern silver impregnated to retard infection, dissolves after 6 weeks

COMPLICATIONS: ACUTE 1. Spasm 4. Pneumothorax 2. Access failure 5. Malposition 3. Arterial puncture 6. Air embolus

AIR EMBOLUS: SYMPTOMS 1. Respiratory distress 2. Increased heart rate 3. pulse 5. Cyanosis 4. Poore in the level of consciousness

AIR EMBOLUS: TREATMENT 1. Left lateral decubitus (Durant’s) Position 2 100% O2 3. Vasopressin if necessary 4. Chest compression 5. Aspiration through catheter +/- Mortality decreases from 90% 30% with conventional treatment

COMPLICATIONS: CHRONIC 1. Infection 2. Catheter fragmentation 3. Non-function

Risk Factors Four major risk factors are associated with increased catheter-related infection rates: Cutaneous colonization of the insertion site Moisture under the dressing Prolonged catheter time Technique of care and placement of the central line

Evidence-Based Strategies Selected to Reduce CLA-BSIs Central line-associated bloodstream infections bundle Hand hygiene Maximal sterile barriers Chlorhexidine for skin asepsis Avoid femoral lines Avoid/remove unnecessary lines

Hand Hygiene Cornerstone of any infection prevention program Many studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications Insufficient or ineffective hand hygiene contributes significantly to a greater bacterial burden and subsequent spread of microorganisms within the environment

Hand Hygiene Use of waterless alcohol-base hand rub Most effective and efficient method for hand antisepsis against bacterial pathogens When hands are visibly soiled, they should be washed with soap and water

Efficacy of Hand Hygiene Preparations in Killing Bacteria Best Good Better Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best. Plain Soap Antimicrobial soap Alcohol-based handrub

Maximal Sterile Barriers One study found a 6-fold higher rate of catheter-related septicemia when minimal sterile barriers (sterile gloves and small drape) were used instead of maximal sterile barriers Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.

Chlorhexidine for Skin Asepsis Studies have compared chlorhexidine gluconate (CHG) versus povidone iodine as a skin antiseptic for catheter insertion and routine insertion site care Recent meta-analysis, the use of CHG rather than povidone iodine was found to reduce the risk of CLA-BSIs by approximately 50% in hospitalized patients who required short term catheterization Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136:792–801.

Benefits of CHG 2% CHG in tincture of isopropyl alcohol has rapid bactericidal activity and is effective within 30 seconds after application versus 2-minute period for povidone iodine CHG provides persistent bactericidal activity on the skin and maintains its activity in the presence of other organic material Minimal systemic absorption

Site Selection: Avoid Femoral Lines Insertion of CVCs can lead to serious and sometimes life-threatening complications, whether of mechanical, infectious, or thrombotic origin Higher rate of infectious complications in study comparing femoral lines versus subclavian lines 19.8% vs 4.5%

Avoid and Remove Unnecessary Lines Once placed, there should be periodic, if not daily assessment, of its continued need, with emphasis on prompt removal

Empowerment of Nursing One of the most important steps in preventing CLA-BSIs is to empower the nursing staff to stop the central line insertion procedure if the guidelines were not followed

TYPES OF INFECTION EXIT SITE, TUNNEL/POCKET or CATHETER 1. Cutaneous - pain, erythema, swelling, +/- exudate 2. Bacteremia - fever, leukocytosis and positive blood cultures 3. Septic thrombophlebitis - bacteremia, thrombosis and purulent discharge

INFECTION CAUSATIVE ORGANISMS Staph epidermidis 25-50% Staph aureus 25% Candida 5-10%

INFECTION 1. Septic thrombophlebitis - remove catheter 2. Cutaneous - local treatment 3. Bacteremia - 1. IV antibiotics 48 -72 hours if improved - keep catheter if no change, worse or recurs remove catheter or 2. Exchange catheter over wire, 85% cure with treatment

INFECTION Continue to treat infection for 10 - 14 days If ineffective - try locking with thrombolytics between antibiotic doses and administer antibiotics through catheters

Discharge Teaching For The Patient With A CVC Proper handwashing and principles of sterile technique Dressing change procedure and frequency Flushing and cap change procedure and frequency Observation of cath and insertion site

When to call the physician Temp of 100.5F or greater Chills, dyspnea, dizziness Pain, redness, swelling, or drainage at site Unresolved resistance, pain or fluid leaking while flushing Hole or tear in cath Excessive bleeding at site Change in length of external cath Swelling in neck, face, chest, or arm

General safety measures No sharp objects near cath Clamp cath when not in use No pulling or tension on the cath Discard syringes and needles in sharps container Activity limitations Use a stress loop Home health referral

Discontinuing A CVC Follow the institution’s policy and procedure For percutaneous internal jugular or subclavian insertion sites, place patient in trendlenburg position and have him perform the Valsalva maneuver Remove cath and apply pressure with an occlusive dressing over a petroleum gauze Check cath to ensure tip is intact Document how patient tolerated procedure, placement of dressing and cath tip intact