1. Alternative Access & Complications Catherine Luksic, BSN RN
IV THERAPY PART 4
Alternative Access & Complications
Catherine Luksic, BSN RN

2. Alternative access routes
1. Central Venous Lines - percutaneous
-<60 days, subclavian or internal jugular veins
- Single, double, triple, quad-lumen
- Sutured in place, Sterile dressing change q.7 days
*check policy….may be q hr.
- May require daily heparin flush
**check policy
2. Tunneled catheters – Hickman, Broviac, Groshong
- Percutaneous, tunnelled under skin
- Single, double, or triple lumen
- Long term use 1-2 years
3. PICC lines - Peripherally Inserted Central Catheter
- placed peripherally, longer term use
There are many different types of IV accesses, however, IN ADULTS, anything not PERIPHERAL is CENTRAL. We touched on these earlier, but we will discuss them a little more here. These are lines that are threaded through veins until the tip of the catheter is in the lower one third of the superior vena cava. MUST BE CONFIRMED BY X-RAY BEFORE USE OF LINE!!!!
Although as an LPN you will rarely be providing direct care of a central line, you will still be caring for these patients, so you need to have an understanding of what is being used and the proper care. (You don’t do surgery either ,but you still need to understand it). All of the complications that we discussed apply to central lines, however they can occur more rapidly and be much more severe. MONITOR THE PATIENT CLOSELY!
A central access is usually used for anyone who requires long-term IV therapy (i.e. days to several weeks (30 day limit) - percutaneous central line; longer than 1 month -PICC line; longer than 6 months -tunneled or implanted port) - this is only a GENERAL GUIDE , or if peripheral access is not possible for whatever reason (can vary widely).
Besides the length of time anticipated, the access chosen is also dependent on what is being infused, the patient’s condition, as well as any other circumstances such as resources (does the patient live alone?), activity restrictions (does the patient work?), who will provide the care (family, nurses, ?)
Let’s just review what each of these are all about…….

3. Alternative Access Routes
4. Implantable Ports
Single or double lumen
Single or double port
Metal chamber connected to silicone catheter
POC (port-a-cath)
Requires huber needle to access
Change needle q. 5-7 days
*check policy first

4. 5. Tesio Catheter For hemodialysis use ONLY
Do NOT access, flush, aspirate or administer meds via Tesio
For dialysis staff only !
Require heparin

5. Central Venous Line Most common use = hospital
Usually have multiple lumens
Advantages:
Can be inserted at bedside.
Easy to use
Multi-lumen
Disadvantages:
Requires sterile dressing changes (check policy)
Risk of infection
May require daily heparin flush (if not used continuously)
Requires activity restrictions
These are the central lines that you most commonly deal with in the hospital. They are not meant to be permanent or even semi-permanent, so they are d/ced before patients go home. These are considered “short-term” central lines. <30 days.
Usually placed subclavian, but can also be jugular. Reminder - much higher risk of infection!
Most common are triple-lumen caths (pass out picture). Will have 3 pigtails and each is located at a different site in the cath (proximal to distal), allows different things to be done or run at the same time. FYI - usually use the proximal for blood draws, and the distal for high volume infusions.
Review advantages and disadvantages.
I will demonstrate a central line dressing change. (REVIEW PERRY AND POTTER)

6. Triple Lumen Catheter (TLC) Central Venous Line (CVL)

8. Central Venous Lines

9. Tunneled Catheters Placed surgically in OR
Tunnel is made from surgical site near the subclavian to an exit wound further down on chest. (2 surgical wounds)
Cuff forms a barrier under the skin - stabilizes catheter and prevents bacterial migration into bloodstream
examples : Broviac, Hickman, Groshong
These are not that common, but you may see. (A Groshong can be a tunneled or regular central line – will see at VA)
Remember they are still a central line, but the tunnel along with the cuff decreases the risk of infection.
These can require either daily or weekly care
Again the different type of catheters may have a different number of lumens.
Show overhead picture

10. Groshong Catheter

11. Implanted Ports Relatively common Placed and removed in OR
Common use = chemo
Port is placed in a surgically made “pocket” and sutured in place. Catheter extends into vein from this port/reservoir.
Must be “accessed” for use w/ huber needle
*LPN may NOT access POC
These are used for long-term IV access. They are very common among chemotherapy patients.
These are also tunneled but have a port reservoir which remains under the skin which keeps the risk of infection very low.
There is NO daily care however does require a skilled sterile (gloves and mask) procedure to “access”, need Huber needle (this is bent at a 90 angle and is noncoring - won’t wear away at septum of the port.
A port usually needs to be heparinized at least every 4 weeks when not in use - depends on the manufacturers recommendations
This was an overview of central line and alternative access. Remember, you can have life-threatening problems.
Very important that these lines are secure , infusions running correctly, care provided in timely fashion, and dressing changes for most lines must be strict sterile technique…..

12. Port a Cath (POC)

14. PICC Lines Can be 20x longer than peripheral cath
Can be used up to 1 year (usually less)
Common use = long term antibiotic therapy; TPN
Must be confirmed by xray before use
Advantages:
Can be inserted by specially trained nurse at bedside
Low infection rate
Disadvantages:
Requires daily flush
Limits activity (external catheter)
Cannot use for high pressure infusions
PICC stands for “peripherally inserted central catheter”
Can be single, double, or triple lumen.
Review advantages and disadvantages.
PICC lines have a much lower potential for infection than other central lines.
Good candidates are patients who cannot have a central line in their chest, or for individual physician-choice.
They cannot be used if any type of skin rash, peripheral edema, not practical for a confused patient, and if there is any type of anatomical distortion of the venous pathway it may not be able to be inserted.
In some facilities, LPN’S can provide the care of this line – KNOW YOUR FACILITY POLICY! LPN’s CANNOT insert or discontinue!

15. PICC
Tegaderm CHG
Chlorhexadine gluconate IV securement device (on strip)

16. PICC Lines FLUSHING – used to maintain patency of the line.
Dictated by agency policy.
Most commonly normal saline, followed by heparin. (Volume determined by manufacturer, usually 5-10cc).
Check for allergies, incompatability, bleeding, etc.
Check policy re: heparin use
MUST USE 10cc SYRINGE
Demonstrate the flushing technique. Nurse administering meds will use SASH procedure – however LPN’s do not typically administer meds via central line, so I AM EXPLAINING ROUTINE FLUSH.
Discuss Heparin. Normal for flush is 10U TO 100U/ml, HEPARIN COMES IN WIDE VARIETY OF DOSES – CAN BE 5000U/ML
Each student must demo for me!
FOLLOW THE FLUSHING PROCEDURE FORM THE COMPUTER PROGRAM FOR DEMO PURPOSES – MUST KNOW YOUR AGENCY’S POLICY!

17. PICC LINE CARE CXR MUST BE DONE TO CONFIRM PLACEMENT
ROUTINE IV SITE MONITORING PLUS:
ARM CIRCUMFERENCE (DO NOT USE FOR BP)
TEMP ↑, RESP STATUS, CARDIAC IRREG
EXTERNAL CATH LENGTH – measure, check markings
PATIENT EDUCATION
Absolutely do not use until placement is confirmed by CXR.
Of course the site will be monitored as any IV site with additional considerations
Arm circumference – this can warn of thrombus or other circulatory interruption.
TPR – this is a CENTRAL LINE – we will discuss complications in next classes.
External cath length – to determine if migrating
Education – can’t submerge in water, can’t weight lift, etc. – see p. 587 Perry, Potter

18. Central Lines SCRUB THE HUB APPLY ANTIBACTERIAL CAP BETWEEN USES
15 seconds
APPLY ANTIBACTERIAL CAP BETWEEN USES

20. Central line dressing change
Change as needed and according to institution policy
q hr for CVC or….
Q 7 days for CVC **check policy !
Q 7 days for PICC
Must be performed as sterile procedure
Inspect site at each change
Central line dressings are changed as often as every 3 days(CVC) or as long as every 7(PICC). Of course they should always be changed if needed. This applies to transparent dressings - gauze must be changed every hours (rarely used)
Review procedure, FYI - some books say to use antimicrobial ointment, CHECK YOUR PROCEDURE. For most facilities this is no longer a recommendation.
Some facilities (i.e.: VAMC – uses chlorhexidine patches and 7 day dressing change on central lines, betadine and 7 days for PICC lines.)

22. Central Line Dressing Change
Cleanse from insertion site outward for 4-6 in area
Cleanse site well with alcohol first, then chlorhexadine or povidine-iodine (betadine)
Clean in a circular motion, allow to dry
ASSESS SITE
Apply transparent dressing, reinforce with tape, and LABEL.
Document
This is simply the most common procedure – you MUST check your facilitity
Some facilities (i.e.: VAMC – uses chlorhexidine patches and 7 day dressing change on central lines, betadine and 7 days for PICC lines.)
(PICC line dressings are usually very similar except that the cath might be steri-stripped to prevent movement,and there may be a small gauze under insertion site for drainage for first 24 hours.)
Demonstrate in lab. Follow procedure from Perry/Potter p 610 for CVC, procedure from computer program for PICC.
DOCUMENT ASSESSMENT OF SITE AND DRESSING CHANGE.!

23. Documentation Legal, ethical , and professional responsibility
Includes:
Insertion procedure
Proper infusion and maintenance
Monitoring of site and infusion
Direct care given (i.e. dressings, tubing changes, patient education, etc.)
Documentation is the legal aspect of charting care. As with ALL charting it must be accurate and complete.
Logically:
First your patient assessment - if there was a problem then you should have been aware BEFORE starting the IV- this must be documented.
Insertion procedure - WHERE, WHAT SIZE/LENGTH/ TYPE, ANY PROBLEMS?, BLOOD RETURN?, Patent?, patient toleration.
Infusion - what was started, how fast, WHEN? Once running need to document maintained as ordered.
Site - chart appearance, does it need to be changed (72 hours)
Infusion changes - does bag/tubing/etc. need to be changed. Documentation includes proper LABELING OF ALL TUBING, DRESSING, BAGS, ETC.
All direct care - dressing changes (both at site and in chart), rate changes (Why?), discontinue (why?), patient education given needs to be documented!
Most facilities have an IV sheet (pass out Mercy’s) - be familiar with yours.
Anything above and beyond must be clarified in notes. Again - check your facilities policies and procedures - it is YOUR responsibility to know if something has to be changed.

24. Complications
Systemic - problem involving the entire body, related to IV therapy
Local - adverse reaction or trauma to the surrounding venipuncture site.
Hypersensitivity - can be systemic or local
One of the most important legal aspects of IV therapy is the prevention and prompt recognition and treatment of complications related to IV therapy.
Complications can be systemic or local.
Systemic complications are those that have an effect on the entire body and they can be life-threatening.
Local complications are those that affect the area surrounding the venipuncture site - these can advance to a more life-threatening problem if not addressed.
Hypersensitivity is an allergic reaction and can occur as a systemic reaction to a solution, a preservative, a medication, or to the catheter, tape, antiseptic , etc.
As with all hypersensitive reactions the signs and symptoms can range from hives to bronchial spasm and anaphylaxis.

25. Systemic Complications
Circulatory overload - usually infused too fast, or with hepatic, cardiac, renal disease
Dyspnea, cough, edema, wt. gain, rales or crackles
Decrease IV rate, elevate HOB, obtain vitals & assess the patient, notify physician
Infection (septicemia) - microorganisms in circulatory system
Fever, chills, tachycardia, tachypnea, headache
? IV contaminated, break in aseptic technique
Notify physician, treat symptoms, blood cultures, remove IV
Establish another IV site
Overloading the circulatory system with excessive fluid causing increased blood pressure. Usually from too rapid infusion of fluid or related to hepatic, cardiac, or renal disease. (Can cause CHF or pulm edema)
Need to monitor weight, v.s., I&O, edema, rales in lungs, etc. Pt will have a bounding pulse and rising BP,etc.
If suspect fluid overload, slow the IV, raise the HOB, and notify physician.
Septicemia - this is actually the leading cause of death in ICU’s and rarely does anyone culture the IV fluid or the catheter to know if this is the source. A clot is a source of bacterial contamination and can be pushed into the systemic circulation when irrigating. Watch for fever, tachycardia, altered mental status.
This is why aseptic technique is vital when working with IV’s
Air embolus - usually affects pulmonary circulation. More of a problem with central lines, but possible with any IV. Air is trapped in the circulation and carried to the right ventricle where it lodges against the pulmonic valve so that the blood is not able to flow into the lungs. If it breaks up, then small bubbles are pumped into the pulmonary circulation and make things even worse. Preventable Do not allow bags to run dry, be sure that air is out of lines, Use luer lock connections so central lines don’t pull apart.
Patients usually have very vague complaints - usually palpitations, lightheadedness, anxiety, and dyspnea. Hypotension noted.
Treatment is Trendelenberg, on left side, administer oxygen, call physician

27. Systemic Complications
Venous Air Embolism - rare, but lethal
Air trapped in Rt. Ventricle lodges against pulmonary valve
Blocks flow of blood to pulmonary artery
Right heart overfills
Small bubbles may enter pulmonary circulation
Tachycardia, SOB, shoulder pain, JVD, hypotension, weak pulse, lightheadedness
Immediately – pt. on left side, trendelenburg, notify physician
Causes air to rise in right atrium, prevents air from entering
pulmonary artery
Obtain vitals and pulse oximetry, administer oxygen
Left, trendelenburg to prevent PE from travelling through pulm artery & with air embolus – to disperse air back into right atrium
Med surg book says HOB up with PE – IV book says left trendel. w/ air embolus

28. Systemic Complications
Speed Shock - foreign substance (usually medication) is rapidly introduced into circulation
Usually results in hypertension
Slow infusion rate, notify physician
Vancomycin = “red man syndrome”
Incompatibility
Drug interactions
Allergic reaction
speed shock - same problem that causes fluid overload, too rapid infusion!
If at all possible, use a pump for all IV meds, otherwise must monitor VERY carefully, remember patient position can change the rate of the IV.. Prevention is truly the key for this complication.
Incompatibility - we talked about this several times. It is YOUR responsibility to know if a med can be administered with a solution. Remember many IV’s have potassium added, or there may be another med infusing. Some meds and solutions can interact (possibly very badly), and some are just completely incompatible.
Some facilities simply won’t allow certain meds to be given IV by ANY nurse or at least on the floor (VAMC has a whole list – nurses must know it)
Pass out incompatibility chart. These can be found everywhere including pharmacy – you will never remember them all – it os YOUR responsibility to look it up! Although you do not administer many of these meds, you will notice that antibiotics, heparin, and potassium are on this chart!
Treatment of any systemic complication is immediate notification of charge nurse and/or physician

29. redmans

30. Local Complications *Common area for nursing malpractice
Phlebitis - Inflammation of the vein, common
Redness, pain, swelling, induration
*symptoms worse w/ thrombophlebitis = clot
Remove IV and relocate
Tx: Warm compresses
Prevention = rotate sites every 72 hours
ASSESS site hourly !
Although less risk of life-threatening problem, this is more common and can worsen if not identified. COMMON AREA FOR NURSING MALPRACTICE IS NERVE INJURY, INFILTRATION, AND EXTRAVASATION.
Phlebitis - site is tender to touch and can be quite painful. IV SHOULD BE CHECKED AT FIRST SIGN OF REDNESS OR PATIENT COMPLAINT. Difficult to defend phlebitis in court.
regardless of cause appearance is same.
Mechanical - irritation from a cannula that is too big in little veins (less of problem in large arm veins), manipulation of the catheter during infusion, improper taping - use a chevron to secure!
Chemical - inflamed vein from an irritating solution or medication. Again, very small veins, potassium can be VERY irritating (especially if greater than 30mEq/L), continuous infusions (locks are less likely to develop chemical phlebitis)
Bacterial - (septic phlebitis) uncommon and associated with a bacterial infection. Usually due to poor handwashing and poor aseptic technique.
(This is why sites are NOT shaved before initiating IV)
Treatment is to discontinue, elevate, and apply warm compresses. NV checks.

32. Local Complications
Infiltration - seeping of fluid into surrounding tissue
Site is cool with dependent edema, and often painful.
Tx: Discontinue IV solution, remove catheter, apply warm compresses, elevate extremity
Prevention = hourly IV site checks !
Infiltration - can be secondary to phlebitis. Usually a mechanical cause such as dislodging, poorly secured, high pump rate, overmanipulation.
Infusion will often continue to flow! Treatment can be warm or cold soaks - check with physician.
Imperative to document the size of the infiltration if possible – pts usually bring pictures of the infiltrated arm to their lawyers – a small area can show proper monitoring, however a large area implies infrequent monitoring of the site.

34. Local Complications
Infection - related to microbial contamination of the catheter or the infusate
Extravasation - infiltration of a vesicant medication, can cause blisters and subsequent sloughing of tissues
Chemo
IV potassium at higher concentration (over 40meq)
Dopamine
Dilantin
Flagyl
Local infection - should be preventable by good technique and following guidelines for changing sites, tubing, and infusates. The s/s are similar to phlebitis except sometimes have purulence. Tx: d/c catheter and culture site.
Extravasation - this can be extremely nasty. same cause as infiltration. KNOW YOUR MEDS AND FLUIDS - IF VESICANT, DON’T EVER INCREASE TO SEE IF INFILTRATED!
As an LPN, you will not administer most of these meds, but may be caring for the patient. Usual meds are antineoplastic meds, Dopamine (commonly used), High potassium, calcium, and sodium bicarb.
If occurs - do NOT PULL IV, just stop immediately - may use line for antidote. Usually use ice and elevation - may need plastic surgery consult.
Documentation is vital - may even need photographs - CHARGE NURSE.
Remember extravasation can lead to permanent damage and possible limb loss.
NOTE: Standard 43 Site Selection, Practice Criteria for Peripheral — Short and Midline Catheters reads as follows:"Therapies not appropriate for peripheral-short catheters include continuous vesicant chemotherapy, parenteral nutrition formulae exceeding 10% dextrose and/or 5% protein, solutions and/or medications with pH less than 5 or greater than 9, and solutions and or medications with osmolarity greater than 500 mOsm/L. "
Quiz #3 - on Complications, next class.

36. Local Complications
Hematoma – infiltration of blood into extravascular tissues
SQ hematoma is a localized collection of blood and is the most common local complication.
May see discoloration of skin
Usually related to nursing skills
Higher risk in pts. on anticoagulants
Higher risk in elderly
Want to also mention “hematoma” which can occur on insertion of an IV because of bleeding - can be caused by poor technique or too tight tourniquet. Patients at risk are those with fragile veins, and those on anticoagulants.
Ecchymosis is more diffuse bleeding.

37. Preventing Complications
Use aseptic technique
HANDWASHING
Inspect all fluids & equipment before use
Be alert to signs of circulatory overload
JVD, elevated BP, elevated RR, moist crackles, edema
weight gain
Anchor IV cannula well to prevent motion
Do not use veins over area of joint flexion

38. PN Scope of Practice Must complete state approved infusion course
Must attend annual review (CEU’s) to maintain skills
May not administer meds which require titration (insulin, heparin, cardizem, etc.)
May not administer blood products
May administer saline flushes & heparin flushes
May administer TPN & lipids

39. PN Scope of Practice
Peripheral Line: may insert & D/C, flush, change tubing, site care
PICC Line: may not insert or D/C; ok to flush, change tubing, site care, draw blood
?? Check hospital policy !
Central Line: may not D/C; ok to flush, draw blood, change tubing and perform site care
POC: may NOT flush or access, may not draw blood, may change tubing and administer IVPB

40. PN Scope of Practice Guidelines are provided by State Board of Nursing
MUST always follow institution policy – this may vary from state guidelines

41. INS Standard
The nurse shall educate the patient, caregiver, or legally authorized representative:
Prescribed infusion therapy
Plan of care
Potential complications associated with therapy
Peripheral or Central
Risks
Benefits