1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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.

21. 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

22. 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:

23. 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

24. 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

25. 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

26. 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