Central Venous Catheters

Overview of Presentation

Differentiates between types List flushing techniques Discuss insertion Describe dressing change procedure Explain procedure for accessing ports Identifies complications Recognize nurses role in preventing infection

Central Venous Catheters

http://www.nursing-standard.co.uk/archives/ns/vol14-43/pdfs/4550w43.pdf

Types of Central Venous Catheters

Non-tunneled-placed percutaneously directly into vessel. Skin sutured at insertion site. Temporary-usually less than a couple of weeks. Example-triple lumen Arrow

Tunneled
Surgically tunneled through tissue, then into vein. Often with cuff that helps decrease infections Types-Broviac, Hickman, Groshong

What is the difference between tunneled and non-tunneled?

This is a tunneled catheter

This is the cuff

A Hickman or Broviac are both examples of tunneled catheters. They are placed in the OR or in interventional radiology (if a doctor inserted it in the ICU, it is not tunneled!). Nurses do not remove these. When you look at a tunneled catheter, it doesnt have the wings that are used for sutures. Also, you can feel a bump a inch or two away from where the catheter comes out. This is the cuff, a piece of material that grows into the tissue to keep microbes out.

No Wings!

Wings!

This is not a tunneled catheter

Ports

Implanted under skin, thus must be accessed. Decreased infection rates May last months-years Types-Passport, porta-cath

Non coring needle

Implanted ports are to be accessed by noncoring needles only The use of standard blunt angle needles can lead to degradation of the port and potential for embolization of port materials

PICCs
Percutaneously placed central catheters Long catheters placed in arms, legs Comfortable to patient, but high complication rate from infections, catheter rupture

Flushing Central Venous Catheters

Identify catheter type correctly Use alcohol to prep Smaller than a 10 ml syringe will exert higher pressure on the catheter. Always apply minimal force to activate a flush. Must use CVL Heparin order sheets to obtain heparin and chart flushes on MAR.

(STAMP PLATE)

IV FLUSH ORDERS ADULT

Heparin Flush Orders for Adult Central Venous Temporary or Tunneled Dialysis/Pheresis Catheters 1. 2. 3. Withdraw 5 ml of blood from the lumen and discard prior to using the lumen. If both lumens are going to be used, withdraw and discard 5 ml of blood from each lumen. Flush the lumen(s) to be used with 10 ml 0.9% sodium chloride. Following use for intermittent IV fluids, medication administration, or blood sampling: a. Flush the Lumen(s) with 10 ml 0.9% sodium chloride. Using heparin 5000 units/ml, load the lumen with the volume indicated on the lumen. b.

c. Flush dialysis/pheresis catheters twice per week as described above when the lumens are not being used. Heparin Flush Orders for Adult Peripherally Inserted Central Venous Catheter (Standard or Tunneled) 1. Following use for intermittent IV fluids, medication administration, or blood sampling: a. Flush lumen with 10 ml 0.9% sodium chloride. Flush lumen with 5 ml of heparin 100 units/ml. b.

c. If lumen has not been used, flush as above Q 12 hours. d. Must use 10 ml syringes or larger for flushes Heparin Flush Orders for Adult Central Venous Chest Port and/or Pasport (peripherally inserted into an upper extremity) 1. Following use for intermittent IV fluids, medication administration or blood sampling: a. Flush with 20 ml 0.9% sodium chloride. Flush with 5 ml of heparin 10 units/ml. b. c. Flush each Huber needle extension set (may be dual chamber port) as above at least once every 24 hours. d Must use 10 ml syringes or larger for flushes. De-accessing port: a. Flush each Huber needle extension set (may be dual chamber port) with 20 ml 0.9% sodium chloride. Flush each Huber needle extension set with 5 ml of heparin 100 units/ml. b.

2.

c Must use 10 ml syringes or larger for flushes. d Flush port (each septum) every 30 days when not in use Heparin Flush Orders for Adult Tunneled Central Venous IV Catheters (Single or Multi-Lumen, i.e., Hickman) 1. Following use for intermittent IV fluids, medication administration, or blood sampling: a. Flush the lumen(s) with 10 ml 0.9% sodium chloride. Flush the lumen(s) with 5 ml heparin 10 units/ml. b. c. Flush lumens at least Q 12 hours during intermittent use. Flush all lumens with 5 ml heparin 100 units/ml at least q 24 hours when not in use. d. Heparin Flush Orders for Adult Non-Tunneled Central Venous IV Catheters (i.e. Arrow Multi-Lumen and/or Sheath Introducer) 1. Following use for intermittent IV fluids, medication administration, or blood sampling: a. Flush with 10 ml 0.9% sodium chloride. Flush with 1 ml of heparin 10 units/ml. b.

c. Flush all lumens of central IV catheter at least Q 12 hours Flush Orders for IV Access When Heparin is Not Indicated 1. Following use for intermittent IV fluids, medication administration or blood sampling: a Flush peripheral catheter with 3 ml 0.9% sodium chloride Q 12 hours. b Flush central venous catheter (each lumen, as applicable) with 10 ml 0.9% sodium chloride Q 12 hours.

Careful!!!

Dialysis catheters are locked with 5000 unit/ml heparin for each lumen. Dialysis catheters can only be accessed by a non-dialysis RN after an order by the renal fellow or attending. Dialysis catheters should only be removed by nurses trained to do so (ICU and Dialysis RNs)

Insertion

Must use full barrier precautions (mask, hat, gloves, gown, full sterile sheet) The physician will confirm correct placement. Methods for confirmation include imaging, transducing and ABG sampling

Maintenance

All CVCs must be assessed initially and every 2 hours thereafter. Document any changes. Tubings, caps are changed q 72 except for TPN with lipids, which is changed q 24 If new CVL is inserted, new tubing must be used. Leur-lock caps must be used at all times except for transduced catheters (i.e. CVP) Large bore catheters used for introduction of pulmonary artery catheters should be removed or changed to smaller lumen catheters when pulmonary artery catheter is no longer needed

Dressings
Change opaque dressings q 24 Change transparent dressings every 7 days or when no longer occlusive Aseptic technique-use CVL dressing kit with mask Notify MD and Infection Control of suspected infection Use Chloraprep and Biopatch

Chloraprep and Biopatch

Use Chloraprep on all patients except ones that have an allergy to it. Not for use during LPs Biopatch is not used in the nurseries, but used everywhere else.
Line up slit in biopatch with catheter

Scrub vigorously back and forth, not round and round

Blue side to the sky

Removing CVCs

RNs can only remove non-tunneled catheters. Only ICU and dialysis RNs competent to do so may remove dialysis catheters.

Position patient with head as low as possible. Remove sutures and pull line with steady motion as patient holds breath or during expiration. Assure tip is present. For PICCs, see measurement obtained at time of insertion. Hold pressure until bleeding stops, apply dressing.

Complications-Occlusion

Follow occlusion management protocol as per unit policy Consult with MD and clinical pharmacist to decide correct solution (for thrombus or precipitate)

Infection Control
Did you know?
Up to 20% of patients with blood stream infections (BSI) from central lines die? The cost of each BSI can be up to 30,000-much of which the hospital does not get reimbursed for? Grouping interventions together can decrease infection rates than implementing single interventions alone? This is called a bundle

Institute for Healthcare Improvement, 2006

What is a bundle???
A bundle is a selected set of elements of care distilled from evidence-based practice guidelines that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone
Institute for Healthcare Improvement, 2006

Central Line Bundle

Hand Hygiene Maximal Barrier Precautions Upon Insertion Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection, with Subclavian Vein as the Preferred Site for Non-Tunneled Catheters Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Insertion

Site selection-recommended site in adults is the subclavian site. For pediatrics-no data. Full barrier precautions should be used-MDs should use gown, hat, gloves and mask. If you are in and out of the room, wear a mask. If you stand there the entire time, you should use full barriers, too. Antibiotic impregnated catheters recommended

Flushing

When flushing multiple lumens, do not use the same syringe for flush. Properly prep leur-lock injection site-all the time. Use positive pressure flush to keep line from clotting. Meticulous technique importantone slip up can introduce pathogens into your patients bloodstream.

Remember.
Try not to let the end of the tubing hit the floor.

Or take the cap off with your teeth.

And, wash your hands!!!!!!!!

You cant be too clean!!!

http://www.learnovation.com/johnwise_samples.htm

Test!!
1.

Monitor CVL site and catheter connections on initial shift assessment and assess thereafter:
a) b) c) d)

At minimum every 8 hours. At minimum every 2 hours. At minimum every 4 hours. CVLs only need to be assessed on initial shift assessment.

Test!
2.

Personnel involved with CVL placement must adhere to maximum barrier precautions which includes:
a) b) c) d)

Sterile gloves and a mask Sterile gloves, large sterile drape and a mask Sterile gloves, mask, sterile gown and cap Sterile gloves, mask, sterile gown, cap, and large sterile drape

Test!
3.

All of the following statements pertaining to CVL flushes are true except:
a)

b) c) d)

Catheters without continuous infusions should be flushed according to the pediatric or adult IV flush order forms. A physicians order is not required for heparin flushes. Always apply minimal force to activate a flush. Scheduled heparin and saline flushes must be documented on the MAR.

Test!
4.

TRUE or FALSE Large bore catheters used

for introduction of pulmonary artery catheters should be removed or changed to smaller lumen catheters when pulmonary artery catheter is no longer needed

Test
5.

Recommended strategies for nurses to assist with getting blood return from a partially or completely occluded catheter include all of the following except:
a) b) c) d)

Ask patient to deep breathe Examine catheter for kinks Place patient in knee chest position Forcefully flush CVL

Test
6.

TRUE or FALSE Both the adult and pediatric IV flush orders contain a section that allows MDs to order 0.9 sodium chloride flush only.