Transcript Central Venous Catheters

IV TERAPY &
Central Venous Catheters
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
Key points
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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.
Known Complications
of IV Therapy
Phlebitis
Contributing factors:
• Catheter material
• Site of insertion
• Duration of cannula
• Dilution of solution
• Insertion in ED
• Frequency of dressing change
• Presence of infection
• Catheter size
• Skill of operator
• Type of infusion
• Host factors
• Type of skin prep
Infection
Contributing factors:
• Contaminated infusions
• Inadequate skin preparation
• Poor technique
• Host factors
Extravasation
Contributing factors
• Age
• Site of cannula
• Type of cannula
• Duration of cannula
• IV drug infusions
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.
Skin prep
Antiseptic solution - 70% isopropyl alcohol,
0.5 - 1% Chlorhexidine.
Use an aqueous based alternative if there is a
known allergy to alcohol
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)
Reasons For Inserting Central
Venous Catheters
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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
Type of CVC Inserted Depends On
Patient’s condition
 Anticipated length of therapy
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Types Of Central Venous
Catheters
Nontunneled central catheters
 Tunneled central catheters
 Peripherally inserted central catheters
(PICC)
 Implantable ports
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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
Nontunneled Central Venous
Catheters
Used for short-term therapy
 Inserted percutaneously
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 Subclavian
vein
 Internal jugular vein
 Femoral vein
Has from 1 to 4 lumens or ports
 Usually from 6 to 8 inches in length
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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
TUNNELED CATHETERS
1. Single or multiple lumens
2. Flow - variable
3. Long term
4. Easy access (no skin puncture)
5. Cuff - Dacron, vita
Tunneled catheter with cuffs
Tunneled catheter
Tunneled Central Venous
Catheters
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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
Peripherally Inserted Central
Catheters (PICC)
Used for intermediate to long term therapy
 May be single or double lumen
 Inserted percutaneously
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 Basalic
vein
 Cephalic vein
Threaded into the superior vena cava
 May be inserted by specially trained RN
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PICC LINES
1. Silastic or polyurethane
2. Single or double lumen
3. Low flow
4. Short - long term
5. Easy access
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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
SUBCUTANEOUS PORTS
1. Single or double lumen
2. Flow - most commonly slow
3. Long term
4. Access requires needle puncture
SUBCUTANEOUS PORTS
5. Less maintenance
6. Activity is unlimited after site heals
7. Cosmetically more appealing
8. Concealed pocket retards infection (?)
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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
SUBCLAVIAN VEIN
COMPLICATIONS
STENOSIS
THROMBOSI PINCH OFF
SYNDROME
Subclavian vein (SCV) access is prone to more complications than internal
jugular vein (IJV)
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
CENTRAL VENOUS
CATHETER PLACEMENT
1. Prep
2. Access
3. +/- Tunnel
4. Secure
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) 30-60 min. prior
Cefazolin (Kefzol, Ancef) 1 gm IV or
Gentamycin 80 mg IV
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
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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
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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
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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
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
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
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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
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
 For
drawing blood specimen
Discard initial sample of blood
Collect specimen
Flush with 10cc saline
Flush with Heparin solution if
indicated
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Monitor for complications
Infection
 Phlebitis
 Septicemia or pyrogenic reaction
Air embolism
Thrombosis/occlusion
Extravasation
Damaged cath
COMPLICATIONS
1. Acute
2. Sub-acute
Procedural
Infection
3. Chronic
Infection
Catheter fragmentation
Non-function
COMPLICATIONS:
ACUTE
1. Spasm
4. Pneumothorax
2. Access failure
5. Malposition
3. Arterial puncture
6. Air embolus
AIR EMBOLUS: SYMPTOMS
1. Respiratory distress
2. Increased heart rate
3. pulse
5. Cyanosis
4. Poore in the level of consciousness
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%
30%
with conventional treatment
COMPLICATIONS:
CHRONIC
1. Infection
2. Catheter fragmentation
3. Non-function
Risk Factors
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Four major risk factors are
associated with increased catheterrelated infection rates:
 Cutaneous
colonization of the
insertion site
 Moisture under the dressing
 Prolonged catheter time
 Technique of care and placement of
the central line
Evidence-Based Strategies
Selected to Reduce CLA-BSIs
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Central line-associated bloodstream infections
bundle
Hand hygiene
Maximal sterile barriers
Chlorhexidine for skin asepsis
Avoid femoral lines
Avoid/remove unnecessary lines
Hand Hygiene
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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
Hand Hygiene
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Use of waterless alcoholbase hand rub
 Most
effective and efficient
method for hand antisepsis
against bacterial pathogens
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When hands are visibly
soiled, they should be
washed with soap and
water
Efficacy of Hand Hygiene
Preparations in Killing
Bacteria
Good
Plain Soap
Better
Antimicrobial
soap
Best
Alcohol-based
handrub
Maximal Sterile Barriers
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One study found a 6-fold
higher rate of catheterrelated 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.
Chlorhexidine for Skin Asepsis
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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 CLABSIs 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.
Benefits of CHG
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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
Site Selection: Avoid Femoral Lines
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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%
Avoid and Remove Unnecessary
Lines
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Once placed, there should be periodic, if
not daily assessment, of its continued
need, with emphasis on prompt removal
Empowerment of Nursing
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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
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
INFECTION
CAUSATIVE ORGANISMS
Staph epidermidis 25-50%
Staph aureus
25%
Candida
5-10%
INFECTION
1. Septic thrombophlebitis - remove catheter
2. Cutaneous - local treatment
3. Bacteremia 1. IV antibiotics 48 -72 hours
if improved - keep catheter
if no change, worse or recurs
remove catheter
or
2. Exchange catheter over wire,
85% cure with treatment
INFECTION
Continue to treat infection for 10 - 14
days
If ineffective - try locking with
thrombolytics between antibiotic doses
and administer antibiotics through
catheters
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
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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
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
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Discontinuing A CVC
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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