Central Venous

Access Devices
(CVADs)
Chapter 17
Case Study
R.J. is a 54-year-old African- iStockphoto/Thinkstock

American male who is admitted to

the hospital with a diagnosis of
infective endocarditis.
R.J. will need IV access for
extended antibiotic administration.
What type of IV access would be
most appropriate for R.J.?

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Objectives:

What is the definition of a CVAD?

What are the different types of CVADs?

Why are CVADs used?

How do you care for the different types of

CVADs?

What are the complications associated

with CVADs?
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What is a CVAD?
Catheters Three main types
placed in large Centrally
blood vessels inserted
Subclavian catheters
vein, jugular Peripherally
vein inserted central
catheters
Location:
Implanted ports
Tip (SVC, IVC
or RA)

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Indications
Medication Nutritional
administration replacement
Cancer Blood samples
Infection
Blood transfusion
Pain
Renal failure
Drugs @ risk for
phlebitis Shock burns
Epoprostenol Hemodynamic
Calcium chloride monitoring
Potassium chloride Autoimmune
Amiodarone diseases

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 Types of CVAD

Centrally inserted catheters (CVCs)

Short-term, non-tunnelled CVAD - inserted
directly into a central vein
Long tern, tunnelled CVAD inserted
under the skin
Peripherally inserted central catheters
(PICC)
Implanted Venous Access Device or
Implanted infusion ports (Port-a-Cath)

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Why use CVADs?
Permit frequent, continuous, rapid, or
intermittent administration of fluids and
drugs
Allow for giving drugs that are potentially
vesicants (chemotherapy)
Used to administer blood/blood products and
parenteral nutrition
Used for hemodynamic monitoring (CVP)
Useful for patients with limited peripheral
vascular access or need for long-term
vascular access

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 Advantages
Reliable long term access
Immediate access
Used for multiple blood
samples
Used for blood products,
meds, TPN & fluids
Removes need for constant
venipuncture or peripheral
punctures
Decreased risk of
extravasation
Patient preference
Disadvantages
risk of systemic infection
risk of thrombus
Invasive procedure
Exposes patient to risk
during insertion
(pneumothorax)
Can affect body image
Can be traumatic to patient
and may require general
anesthetic for insertion
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 Key Principles In CVAD
Management

Prevention of infection

Maintaining patency

Preventing damage

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 Centrally Inserted Catheter
(Central Venous
Catheter/Central
Inserted into a vein in Line)
the neck, chest, or
groin with tip resting
in the distal end of the
superior vena cava
Nontunneled or
tunneled
Dacron cuff stabilizes
catheter and
decreases incidence of
infection

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Placement of CVAD

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 Short-term, Non-tunneled
Central Catheter

Non-Tunneled (acute, short

term use) Inserted into jugular, femoral or
subclavian vein
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Long-term, Tunneled Central
Catheter

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 Centrally Inserted
Catheter
Single, double,
triple, or quad
lumen
Examples of long-
term (tunneled)
catheters
Hickman
Broviac
Groshong

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15
 What is a PICC line?
Peripherally Inserted
Central
Central venousCatheter
catheter inserted into
a vein in the arm
Inserted at or just
above anticubital fossa
Cephalic or basilic vein
For patients who need
vascular access for 1
week to 6 months
Cannot use arm for BP
or blood draw

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Peripherally Inserted Central
Catheter

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PICC
Advantages
Lower infection rate
Fewer insertion-related
complications
Decreased cost
Complications
Catheter occlusion
Phlebitis

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 PICC
Inserted in antecubital region and
threaded into central circulation
Very soft and flexible, easily damaged
Lower risk of infection
No BPs or venipuncture on that arm
May be removed by RN once
observed
Single or double lumen Tip
May be an open or a closed system

Insertion
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Implanted Infusion Port

Central venous catheter

connected to an implanted,
single or double
subcutaneous injection port
Port is metal sheath with
self-sealing silicone septum

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Implanted Venous Access
Device
Left in place until treatment
complete, or complications occur
Located beneath the
subcutaneous tissue
Appears as a palpable
protrusion under the skin
Lower risk of infection
May only be accessed with a
special HUBER-point needle
with deflected tip
Needles to be changed every 7
days, or every day if infusing
TPN/blood products

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Implanted Infusion Port

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Implanted Infusion Ports
or IVAD

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Implanted Infusion Port
Drugs are injected through skin
into port
Advantages
Good for long-term therapy
Low risk of infection
Cosmetic discretion
Care requires regular flushing
AVOID formation of sludge within
port septum

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Case Study

The IV team nurse just

iStockphoto/Thinkstock

completed insertion of a PICC

line into R.J.s right basilic vein.
1. What must you do before
administering the IV antibiotic via
the PICC line?
2. For what complications will you
monitor R.J.?

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 Complications
Catheter occlusion Management
Clamped or kinked Teach pt to change
catheter position, raise arm and
Tip against wall of cough
vessel Assess for and alleviate
Thrombosis clamping or kinking
Precipitate buildup in Flush with NS using 10-
lumen mL syringe-DO NOT
force flush
Clinical s/s
Perform fluoroscopy to
Sluggish infusion or
aspiration determine cause and
Unable to infuse and or site
aspirate Administer
anticoagulant or
thrombotic agents
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Complications
Embolism Management
Catheter breaking
Give O2
Dislodgement of
thrombus Clamp catheter
Entry of air into Place on left
circulation side with head
Manifestations down (air
Chest pain emboli)
Respiratory distress Notify provider
Hypotension
Tachycardia

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Complications
Infection
Manifestations
Local: redness, tenderness, purulent drainage,
warmth, edema
Culture drainage from site
Warm, moist compress
Remove catheter
Systemic: Fever, chills, malaise
Blood cultures
AB Rx, Antipyretics, Remove catheter

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 Preventing Infection
Strict handwashing
Use sterile technique
Change dressings as recommended
Occlusive dressing over exit site
Keep system closed as much as possible
Change tubing, solutions and injection
caps as recommended
Monitor for early signs of sepsis

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 Complications
Pneumothorax
Perforation of visceral pleura
S/S: decreased or absent BS, Resp. distress,
chest pain or distended one side of chest
Management: O2, Semi-fowlers, chest tube
Catheter migration
Improper suturing
Trauma, forceful flushing
Spontaneous

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Case Study
iStockphoto/Thinkstock

1. What can you do to

maintain patency of the
PICC?

2. What will you teach R.J.

about proper care of the
PICC line?

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Nursing Management
Inspect catheter and insertion site
Assess pain
Change dressing and clean
according to institution policies
Transparent semipermeable dressing
or gauze dressing
Chlorhexidine preferred cleansing
agent

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Cleaning Site with
Chlorhexidine Swabs

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Transparent Dressing Over
Insertion Site

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Central Line Dressing

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Maintaining Patency
Patency is the ability to:
Infuse through a catheter
Aspirate blood from a catheter

Maintain patency with saline flushes:

Prior to and after meds, TPN, etc.
Before and after blood draws
Refer to hospital policy

Methods of flushing include:

Turbulent or pulsatile flush (creates turbulence and
potential for debris to stick to inside or tip of catheter)
Positive pressure (prevents backflow of blood into end of
catheter)

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Preventing Damage

Proper securement of CVAD

is vital in preventing the
following complications:
Catheter migration
Phlebitis
Damaged catheter

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Nursing Management
Change injection caps
Have patient turn head to opposite
side
Valsalva if no clamp
Flushing is important
Normal saline prefilled syringe
Use only 10 ml syringe or larger
Flushing technique important

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Case Study
iStockphoto/Thinkstock

R.J. completes his required

IV antibiotic regimen and
returns to the clinic for
removal of his PICC line.
Describe how you will
remove the PICC line.

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Removing CVADs
Should be done according to
institution policy
Gently withdraw while patient
performs the Valsalva maneuver
Apply pressure
Ensure that catheter tip is intact
Apply antiseptic ointment and
dressing

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