N26: CVAD General Concepts Spring 2012 Your Mission…. Prevention and Early Detection!!!!! Quality Improvement Evidence-based practice Teamwork and Collaboration Safety “minimize risk of harm to patients and providers through both system effectiveness and individual performance” c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Indications Long-term Caustic meds TPN (dextrose content > 10%) Monitor RA pressures Dialysis Multiple therapies No peripheral access Frequent blood sampling Long-term is weeks, months, or years. SEE Table __ in Phillips book. Very good table comparing the types – features, advantages, and disadvantages. This essentially answers objective # 3. Caustic meds: chemo, high or low pH, some antibiotics, c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 What’s in a Name? Central Venous Access Device (CVAD) CVC Central line By type (percutaneous) TLC (triple lumen catheter), PICC By site subclavian, jugular, femoral By brand name (tunneled) Broviac, Hickman, Groshong, Mediport c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 What’s the Difference? Similarities Tip of catheter in a “central” vein: Superior vena cava Differences How/where it is inserted Length of stay c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Method 1: Percutaneous Needle stick, through skin, directly into vein. Central (7 days-Phillips) PICC (> 7 days to several months) Single, double, or triple lumen Triple: proximal, medial, distal ports Short term – higher rate of infection & other complications. No more than month c. Madsen RN, MSN

PICC line Peripherally Inserted Central Catheter N26: CVAD General Concepts Spring 2012 PICC line Peripherally Inserted Central Catheter A PICC (Peripherally Inserted Central Catheter) line is a flexible hollow tube placed in a vein in your arm, most often above the elbow.  The PICC line is about 18 to 24 inches long and goes into the large vein near your heart.  It can be left in for a longer period of time than a midline catheter. There will be one, two, or three lumens (IV access lines) at the end of the catheter where your medicine will be given and labs can be drawn.   A midline catheter is about eight inches long and goes to the level of your shoulder.  It is used as a short-term intravenous (IV) that can be kept in your arm up to 4 weeks. [U of Wisconsin School of Medicine & Public Health] c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Tunneled Surgical procedure Very long-term Exit site: chest or abdominal wall Examples: Hickman Groshong Implanted port (medi-port) Catheter tunneled from insertion site subclavian subcutaneously to an exit site c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 CVAD Insertion Supplies : Check P&P tray antiseptic solution Dressing material CONSENT 10 cc Syringes w/ NS Needleless caps “time out” check list CXR post-insertion c. Madsen RN, MSN

Patient Teaching r/t insertion N26: CVAD General Concepts Spring 2012 Patient Teaching r/t insertion Purpose Position: flat, Trendelenberg keep hands down face covered turn head away c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Complications of CVAD Pneumothorax Malposition SVC syndrome Occlusions Infection Air Embolism Unintentional disruption c. Madsen RN, MSN

Central Venous Catheter Complications — Pneumothorax, Hemothorax, Chylothorax Cause During insertion of CVC, introducer may cause trauma Pneumothorax (collection of air in the pleural space due to trauma to lung) Hemothorax (collection of blood in pleural cavity) Chylothorax (transection of the thoracic duct causes lymph fluid to enter the pleural cavity) Signs and symptoms Pneumothorax Sudden onset of chest pain, SOB On auscultation – crunching sound with heartbeat Dyspnea Tachycardia Hemothorax Same as pneumothorax Hypotension Delayed: dusky skin, hemoptysis Chylothorax Similar to hemothorax Milk-like substance withdrawn into the catheter during insertion

Central Venous Catheter Complications: Pneumothorax Treatment early detection: CXR after insertion Oxygen Monitor vital signs Pressure should be applied over the vein entry site Remove the catheter Chest tube if appropriate CXR: Checking position of tip of catheter as well as looking for pneumo. TKO NS or saline lok until confirmed placement. Can also have pericardial tamponade

Obstruction – Prevention is Key N26: CVAD General Concepts Spring 2012 Obstruction – Prevention is Key Positive Pressure Displacement device Flush unused ports per protocol ‘Push-Pause’ technique Check solution for precipitates Filter if indicated Filter used for TPN c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Flushing a CVAD 10 mL syringe or larger Aspirate for blood return before flushing (INS,2006) SAS or SASH (per hospital protocol) Groshong Catheter – saline only “push – pause” technique Q 12 or 24 hours – per protocol Positive pressure caps flush, remove syringe, clamp Emphasize: NOT THE SAME as giving Heparin as a med; intended for heparin to stay in line. c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Infection CRBSI Exit site infection Catheter tract infection Septic thrombophlebitis Bacteremia Impaired immune system Loss of integrity of intestinal mucosa Direct access to bloodstream Notify MD for : temp spike, sudden increase in blood sugar,lethargy, restlessness, redness or drainage at insertion site. c. Madsen RN, MSN

Central Venous Catheter Complications: Catheter Related Blood Stream Infection (CRBSI) Cause Bacteria or fungi in a patient who has a intravascular device with positive blood culture All BSIs that cannot reasonably be linked to a site of local infection are attributed to CVC Biofilm Contamination Signs and symptoms Same as for septicemia

Central Venous Catheter Complications: CRBSI (continued) Prevention (National Patient Safety Goals) Strict sterile technique Implementation of bundle approach Tunneling and subcutaneous cuffs Antiseptic-impregnated dressing Colonization-resistant polymers Contamination-resistant hubs Luminal antimicrobial flush/lock solutions Good hand hygiene Frequent site assessment NPSG: requires hospitals to “use proven guidelines to prevent infection of blood from central lines’ Frequent site assessment for: Redness, drainage, swelling, moist dressing, integrity of sutures

N26: CVAD General Concepts Spring 2012 CR-BSI “bundle” Hand hygiene Maximum barrier precautions “time out” during insertion prn Chlorhexidine gluconate site disinfection Optimal catheter site (avoid femoral vein) Daily review of line necessity – remove when no longer medically indicated. Central line bundle is a group of EB interventions – when implemented together, result in better outcomes than when implemented individually. The science supporting each bundle component is sufficiently established to be considered the standard of care. use proven guidelines to prevent infection of blood from central lines’ Always: aseptic technique Thorough & appropriate site prep Dressing and tubing changes per protocol Frequent site assessment Observe & maintain skin integrity under dressing Treatment Anti-infective therapy Treatment may be similar to septicemia Prevention is the KEY! Others: (Phillips, 5th ed., p. 483) “time out” if EBP not being followed Feedback re: # of CR-BSI rates Buy-in from CEOs c. Madsen RN, MSN

Systemic Complication: Venous Air Embolism (VAE) Cause Allowing the solution container to run dry and then hanging a new bag Loose connections that allow air to enter system Poor technique in dressing and tubing changes for central lines Presence of air in administration set Factors that must be present: direct communication with source of air Pressure gradient Key factors: Factors that contribute to Morbidity and Mortality: Volume of gas: complications shown w/20 ml.; closer to Rt heart the entry point, the smaller the lethal volume. General rule: 0.3 ml/kg. Rate: Rapid Entry puts large strain on Rt. Ventricle. e.g. forcefully pushed in w/syringe, or deep inspiration while communication w/atmosphere. Patient’s position: more upright, the less neg intra-thoracic pressure.

Systemic Complication: Venous Air Embolism (VAE) N26: CVAD General Concepts Spring 2012 Systemic Complication: Venous Air Embolism (VAE) Signs and symptoms Patient complains of palpitations Lightheadedness and weakness Pulmonary: dyspnea, cyanosis, tachypnea, expiratory wheezes, cough Cardiovascular findings: “mill wheel” murmur; weak, thready pulse; tachycardia; substernal chest pain, hypotension Neurologic findings: change in mental status, confusion, coma c. Madsen RN, MSN

Systemic Complication: Venous Air Embolism (VAE) (continued) Prevention Purge all air from administration sets Use 0.22 micron air-eliminating filter Follow protocol for dressing and tubing changes for central lines Attach piggyback meds to the proximal injection port Use Luer-Lok connectors Do not bypass the “pump housing” of EIDs After removal of central lines initial dressing should be occlusive Prevention No air in line, syringes; check for cracks Luer lock w/ needleless ‘Injection Access Port’. Position w/insertion, removal of CVAD:

Systemic Complication: Venous Air Embolism (VAE) (continued) N26: CVAD General Concepts Spring 2012 Systemic Complication: Venous Air Embolism (VAE) (continued) Treatment Call for help and notify physician immediately Once VAE is suspected, any central line procedure in progress should be stopped; clamp line Place in Trendelenburg position on left side Administer oxygen Maintain systemic arterial pressure with fluid resuscitation and vasopressors Monitor vital signs If circulatory collapse initiate CPR c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 CVAD Dressing Change Prevention of infection is dependent upon effectively reducing the number of microorganisms on the skin Limiting access of the microorganisms to the catheter site. Bio patch often used. c. Madsen RN, MSN

N26: CVAD General Concepts Spring 2012 Discontinuing a CVAD Only for percutaneous Position: Trendelenburg Valsalva maneuver during removal Apply pressure Pressure dressing Go over procedure given in syllabus c. Madsen RN, MSN

Drawing blood from a central line (Dominican procedure) Phlebotomy Instructor Spring 2012 Drawing blood from a central line (Dominican procedure) Turn off IV solutions Flush w/10 mL NS Withdraw 5 mL “discard” Use syringe or vacutainer to withdraw desired amt. blood Flush w/ 20 mL NS Label specimens “line draw” Dominican: turn off solutions for 2 min c. Madsen RN, MSN