1. IV TERAPY & Central Venous Catheters

2. 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

3. 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.

4. Known Complications of IV Therapy

5. 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

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

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

8. 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.

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

10. 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)

11. 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

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

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

14. 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

16. 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

17. 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

18. 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

19. Tunneled catheter with cuffs

20. Tunneled catheter

21. 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

24. 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

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

27. 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

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

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

30. 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

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

34. 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

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

36. 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) min. prior
Cefazolin (Kefzol, Ancef) 1 gm IV or
Gentamycin 80 mg IV

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

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

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

47. 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

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

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

50. 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% %
with conventional treatment

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

52. 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

53. 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

54. 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

55. 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

56. 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

57. 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.

58. 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.

59. 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

60. 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%

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

62. 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

63. 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

64. INFECTION CAUSATIVE ORGANISMS
Staph epidermidis %
Staph aureus 25%
Candida %

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

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

67. 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

68. 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

69. 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

70. 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