Transcript Title Page - Texas Children`s Hospital

Management of Central
Venous Catheters
Theresa Reed, BSN, RN, VA-BC
Manager, Vascular Access Team
and Wound and Ostomy Nurses
Texas Children’s Hospital
Houston, TX
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The single most important thing that you can do to
prevent Vascular Access Device infections is to
perform hand hygiene before you touch any part of
the system.
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When it comes to vascular access, what
device is best for your patient?
• Clear understanding of
options for either low risk
peripheral access or
central access when
infusates require central
administration
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When is a Central Catheter necessary?
• Short peripheral catheters may not always serve the
needs of patients, especially those with difficult to access
veins, even if you have a Vascular Access Team that
uses ultrasound guidance for PIV placement.
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The Infusion Nurses Society (INS) recommendations for
vascular access device (VAD) planning based on:
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•
Prescribed therapy
•
Duration of therapy
•
Vascular characteristics
•
Patient age
•
Comorbidities
•
History of infusion therapy
•
Preference for VAD location
•
Ability and resources available to care for the device
Types of Central Venous Catheters
(CVCs) used at Texas Children’s Hospital
• External
•
•
•
•
Non Tunneled
Tunneled
Tunneled Non-cuffed
PICC
• Implantable port
• Midline – not central
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Non Tunneled CVCs
• The non tunneled CVC
• Inserted directly into the vein
• There is no barrier against
infection
• If bacteria enters at the
insertion site it can travel
directly into the blood
stream
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Non Tunneled CVC
• Used for more temporary
central venous access
• Can be pulled at the
beside
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Tunneled Cuffed CVC
• Tunneled cuffed catheters
commonly referred to as a
“Broviac” or “Hickman”
• Has a tunnel with a Dacron
cuff that adheres to the
subcutaneous tissue
• Cuff is a barrier and an
anchor
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Tunneled Cuffed CVC
• Long term central venous
treatment requiring daily
access
• Since there is a cuff that is
attached to the
subcutaneous tissue the
catheter should be
removed with sedation and
not at the bedside.
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Tunneled Non Cuffed CVC
• In Pediatrics this type of
catheter used to cannulate
the IJ and tunnel down the
chest for better dressing
adherence.
• Most common PICC
catheters are used for this
type of insertion but is
considered a tunneled non
cuffed catheter if it is not in
an extremity.
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Tunneled Non Cuffed CVC
• Long term central venous
treatment requiring daily
access
• Since there is no cuff is
adhered it may be
removed at the bedside
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PICC –Peripherally Inserted Central
Catheter
• PICC catheters are
placed by NCVAT,
Interventional Radiology
or Surgery at Texas
Children's Hospital
(TCH).
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PICC –Peripherally Inserted Central
Catheter
• Placed in an extremity or
the head of a neonate
• Good for short-term
treatment
• Catheter selection is
limited due to patient size
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Types of PICC Catheters
• The Bioflo PICC has a
valve in the hub of the
catheter
• May have to flush with
saline before obtaining a
good blood return.
• Does not require a clamp
on the catheter
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Power Injectable PICCS
• Purple means it is Power
Injectable
• Clamp will have mL/sec
allowed by that catheter
• May still require a PIV for
CT if injector needs to
infuse faster than the
catheter can tolerate.
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NEO PICCS
• Placed by NCVAT in
Newborn Center and
CVICU
• For infusion only, do not
heparin lock due to small
lumen size may occlude
easily.
• Rare for blood sampling,
lumens too small
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Single Vs. Multi- lumen Catheters
• Consider types of
infusions needed for
treatment
• Incompatible drugs
require multiple lumens
• Numerous IV
medications
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Implantable Port
• Implantable ports also
called infusaports or
portacaths are
• totally implanted under the
skin
• is accessed via a Huber
needle that will not core the
silicone top port of the
catheter
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Implantable Port
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Implantable Port
• The Huber needle must
go past the silicone core
of the portal septum and
into the actual reservoir
of the port to function
correctly
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Implantable Port
• Assess the size noncoring needle for each
port
• Too long of a needle may
bend
• Too short may not get
through the silicone septum
• Most common size is ¾ inch
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Power Injectable Implantable Port
• Power Injectable ports can
usually be identified on xray
• Must use a power
injectable needle in
conjunction to use on the
power injector
• Clamp will tell the mL/sec
can be used on the injector(
also for PICCs )
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Implantable Port Pain Protocol
• Topical analgesics for
the implantable port
accesses:
• Vapo-coolant spray
• LMX
• Dressing Removal:
• Brava
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Midline
• Not Central
• No TPN over 12.5 %
dextrose
• No heparin over 10 units/mL
• No vesicants
• Catheter terminates in axilla
or lower on the arm
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Midline
• Lasts up to 30 days
• Not a reliable source for
blood sampling
• Flush with 10u/mL
heparin
• Maintenance the same
as a PICC with a weekly
dressing.
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CVC Policies and Troubleshooting
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CVC Policies
• Do not hand flush with anything less than a 10-mL
syringe due to the larger pressure exerted with smaller
syringes on smaller diameter catheters.
• Smaller syringes need to be on a pump and not hand
flushed
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CVC Policies
• Catheter removal
• Removal of a tunneled cuffed CVC or implantable port is a
medical act and must be done by a physician
• The Vascular Access Team (VAT) or RN with competence
determined by the specific unit may remove a non-tunneled
CVC at TCH
• At TCH there is a specific competency that is completed to
remove a PICC
• The VAT, RN trained by the VAT, or any advanced practice RN, PA, or
physician may remove a PICC
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The dressing assessment
• Upon assessment:
• Dry and intact
• Changed once a week and
PRN
• Dressing are done once a
week
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The dressing assessment
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Skin is cleaned with chlorhexidine
(CHG) when >59 days
•
60 days of age or younger clean
with Povidone Iodine (PVP)
•
PVP appropriate alternative when
patient is sensitive to CHG
•
Biopatch is impregnated with CHG,
the manufacturer has specific
recommendations for use in
pediatrics. TCH, over 60 days of
age.
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Suture Reaction
• Suture reaction
• Start daily dressings with
some type of antibiotic
ointment to the reddened
areas.
• Usually treat for 7 days
• Use a tape that comes off
easily
• PVP since CHG has alcohol
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Suture Reaction
• Day 7 skin is healed.
• Can return to CHG
• If irritation returns can
remove sutures and use
alternative securement
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Alternate Securement at TCH
• Stat Lock
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•
Centurion Device Grip Lok
CHG vs tape Reaction
• Rashes are difficult to
diagnose.
• Tape or CHG reaction
hydrocortisone and change
tape that is used
• Yeast triamcinolone and
nystatin
All Daily dressings for at least
7 days
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Rashes
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TCH Flush Protocol
•  Peripheral line
• Normal saline after meds or every 8 hours
•  Midline
• Heparin 10 units/mL 3 mL after meds or minimally every 8 hours
•  External central line (non tunneled, tunneled, or PICC)
• Heparin 10 units/mL 3 mL after meds or minimally daily
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TCH Flush Protocol
•
Implantable Port – Intermittent
Heparin 10 units/mL 5 mL after meds
Implantable Port – Dormant (Accessed)
• Heparin 10 units/mL 5 mL daily
•
Implantable Port – Not Accessed
Heparin 100 units/mL 5 mL every month and when pulling
needle for discharge.
*Under age 2 years: 10 units/mL 5 mL every month and
when pulling needle for discharge.
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CVC Occlusions
• Smaller gauge catheters used frequently in neonates
and small pediatric patients are associated with higher
incidence of complications.
• These catheters function better if there is fluids running
at a TKO rate it the fluids can be tolerated.
• TKO is different for each patient, the rate it takes to keep
it from backing up.
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CVC Occlusions
• An occlusion occurs when a CVC is no longer patent.
The occlusion can either be partial, which is no blood
return, or complete occlusion which is unable to flush or
get a blood return.
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CVC Occlusions
• Three types of CVC occlusions:
• Mechanical
• Precipitate
• Thrombotic
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Mechanical CVC Occlusions
• Caused by compression of the line by kinked tubing, that
can be internal or external, a catheter secured over a
joint or a clamped line. Another cause is “Pinch Off”
syndrome.
• Caused by a malpositioned catheter.
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Pinch Off Syndrome
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Twiddler’s Syndrome
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PICC Film with Arm
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PICC Film with Arm
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Flipped Implantable Port
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Precipitate CVC Occlusions
• When incompatible medications combine in the catheter
lumen. A sudden occlusion can be a sign that a
precipitation has occurred.
• Smaller vessel size and lack of options for alternate
access, many pediatric patients have single lumen
catheters that require piggybacking to administer
medications.
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Precipitate CVC Occlusions
• Mineral occlusions are typically treated with hydrochloric
acid (0.1 N HCL) due to calcium and phosphorus
precipitations in Parenteral Nutrition.
• 0.1 N HCL is used to dissolve precipitates generated
from acidic agents.
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Precipitate CVC Occlusions
• Mineral occlusions are typically treated with hydrochloric
acid (0.1 N HCL) due to calcium and phosphorus
precipitations in Parenteral Nutrition.
• 0.1 N HCL is used to dissolve precipitates generated
from acidic agents.
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Thrombotic Occlusions
• It is estimated that thrombotic occlusions occur at 60% of
all CVC occlusions.
• Within 2 weeks of insertion most catheters develop a
fibrin sheath, does not indicate catheter malfunction but
can lead to a partial occlusions.
• CVCs with the tip in the lower third of the SVC have a
lower risk of occlusion.
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Thrombotic Occlusions
• Can lead to CLABSI as it provides a perfect medium for
bacteria growth.
• Important to treat a catheter as soon as a potential line
issue is noticed.
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Thrombotic Occlusions
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Thrombotic Occlusion Treatment
• Alteplase (t-PA) is a
tissue plasminogen
activator.
• Dwell in the catheter up
to 2 hours
• No more than 2 mL in
pediatrics in 24 hours.
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Conclusion
• Pediatric patients require CVCs to provide stable and
reliable venous access for treatment.
• Maintenance is crucial for successful treatment .
• An occlusion can lead to:
• Interruption of therapy
• Risk for CLABSI
• Increased health care costs
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Conclusion
• Proper selection of the vascular access device will help
enable successful outcomes
• Clinicians should be aware of the proper care and
management of complications as they arise.
• The quicker the troubleshooting begins, the more likely
there will be resolution and IV therapy can be restored.
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VAT Community Work
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References
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1.
Moureau N. How to establish an effective midline program : case of 2 hospitals. J of the Asso. For Vascular Access.
2015;20(3) pp. 179-188.
2.
Infusion Nurses Society. Infusion Therapy Standards of practice. J. of Infus. Nurs. 2016; 39 (1suppl):S51-S54.
3.
Davis M. Pediatric central venous catheter management : a review of current practice. J of the Asso. For Vascular Access.
2014; 18(2) pp. 93-98.
4.
Ast D. Ast T. Nonthrombotic complications related to central vascular access devices. J of Infus Nurs. 2014; 37(5): 349-358.
5.
Doellman D. Prevention, assessment, and treatment of central venous catheter occlusions in neonatal and young pediatric
patients. J Infus Nurs. 2011; 34 (4): 251-258.
6.
Ullman A. Cooke M. Rickard C. Examining the role of securement and dressing products to prevent central venous access
device failure: A narrative review. J of the Asso. For Vascular Access. 2015; 20(2): 99-110.
7.
Zerla P. Canelli A. Caravella G. et. Al. Open vs. closed-tip valved peripherally inserted central catheters and midlines:
findings from a vascular access database. J of the Asso. For Vascular Access. 2015; 20 (3) : 169-176.
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Questions?
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