Transcript 2011 Introduction to CVADsx

Introduction to CVADS
CCN Nursing Education 2010
Objectives:
Session participants will understand that:
• There are different types of venous access
• Ensuring adherence to policy and procedure is essential
for safety of the patient
• There are multiple complications associated with
CVADs
• Knowledge of the care for the different types is required
prior to utilizing the lines
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Central Venous Access Device
• Venous access device whose tip dwells in the distal
one-third of the superior vena cava.
• Long term tunneled
• Short term non tunneled
• PICC line (peripherally Inserted Central Catheter)
• IVAD (Implanted Venous Access Device)
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CVAD
• Tip rests in a
large central
vein and is
responsive to
changes in
thoracic
pressure
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Why Use a CVAD?
• Prescribed therapy
• Duration of Therapy
• Physical assessment
• Health history
• Support systems
• Patient preference
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Long Term Tunneled
Entrance site
Superior Vena Cava
Dacron Cuff
Line tunneled
under the skin
Exit site
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PICC- Peripherally Inserted Central Catheter
• Inserted in antecubital
region and threaded into
central circulation
• Very soft and flexible, easily
damaged
• Lower risk of infection
• No BP’s or venipuncture on
that arm
• May be removed by RN
once observed
• Single or double lumen
• May be an open or a closed
system
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Groshong Tip
• Special tip designed to
keep line open
• No heparin required
• Pressure to infuse opens
valve and allows fluid to
enter
• Aspirating for blood
opens valve inward to
allow for withdrawal.
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Other PICCS
• Many different types:
• Some have valves in hub that do not require heparin
– Check for clamps, valved lines have no clamps
• Power PICCS
– Used for power injections for contrast with CT
• Open-ended PICCs
– Require heparin if not using positive pressure caps
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Care of lines:
•
•
Vigorously scrub hub
Flush with 20 cc NS
– prior to and immediately after accessing for any use
– Weekly if not in use
•
Flush with 20 cc NS
– Following blood draws, an infusion of lipids,
blood/blood products or medications known to
crystallize or precipitate
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Flushing Guidelines
Open Ended (Non-Valved) CVAD – Adults
Device
Frequency
Solution and Strength
Volume
Implanted Ports
Once a Month
Heparin – 100 units/mL
5 mL
Tunneled
Q 7 days
Heparin – 10 units/mL
5 mL
PICC
Q 7 days
Heparin – 10 units/mL
3 mL
Closed Ended (Valved) CVAD
Device
Frequency
Solution and Strength
Volume
Tunneled
Q 7 days
Normal Saline
10 mL
PICC
Q 7 days
Normal Saline
10 mL
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Injection Cap Changes
•
Injection caps are to be changed on all CVAD lumens
in the following circumstances:
– Every 7 days and as needed in hospital
– Every 4 weeks and as needed in out patient
settings depending on frequency of access of
catheter
– If it is leaking or broken
– If blood is trapped in the injection cap
– If the cap is removed for any reason
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Injection Cap Changes
•
•
•
•
•
Vigorously clean the injection cap/catheter connection
extending 1.5 cm above and below the injection
cap/catheter connection using 70% isopropyl alcohol.
Allow to dry completely
Remove injection cap from catheter lumen using sterile
gauze
Clean outside threads of catheter hub only if visibly
soiled, ensuring antiseptic does not enter the catheter
lumen. Allow to dry
Apply new sterile injection cap to lumen
Flush and lock lumen following injection cap change
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Dressing Changes:
Gauze dressings used
• 24 hrs post-insertion
• If patient allergic or intolerant to transparent dressings
• If the catheter exit site inflamed, draining, or a site infection
suspected
Dressings should be changed:
• 24 hrs post insertion
• Transparent semi-permeable membrane dressings every 7
days and as needed
• Transparent over gauze every 48 hours and as needed
• Gauze dressing every 48 hours and as needed
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Dressing Changes:
• Use sterile dressing tray
• Clean entire area of skin to be covered with dressing
• Use Chlorhexadine swabsticks
– Ensure entire area dry prior to placing dressing
• Securement devices are not needed for tunneled catheters
• Change caps prior to dressing changes
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Stat locks for PICCS
• PICC securement device,
used in place of sutures
• Change with each dressing
change
• Remove old dressing and
device with clean gloves
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Removal of StatLock
•Lift edge of anchor pad using alcohol
swabs
•alcohol will dissolve undersurface of
pad away from skin.
•Stabilize catheter while holding the
StatLock® device
•Use thumb of opposite hand to
gently lift door from behind, while
pressing down with index finger
•Lift PICC from holder, and place to
the side
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Adding new StatLock
• Using Sterile technique, cleanse
entire site with Chlorhexadine
• Allow to dry completely
• Apply provided skin protestant to
securement site
• Align anchor pad so directional arrow
points towards insertion site
• Peel away paper backing from
anchor pad, one side at a time, then
place on skin
• Apply transparent dressing
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Suture removal for tunneled catheter
A physician/NP’s order is required to remove sutures.
•
At the insertion site, 7 days post
•
At the exit site/catheter skin junction, typically 10
to 14 days post tunneled CVAD insertion
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IVAD – 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 non-coring needle
• Needles to be changed every 7 days or days if infusing
TPN/blood products
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IVADs
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IVADs
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IVAD Accessing
• Sterile procedure
• Flush needle with saline prior
to insertion
• Locate portal septum by
palpating it under the skin
• Scrub entire area to be covered
with dressing with
chlorhexadine
• Hold port securely between two
fingers. Push the needle at a
90 degree angle to skin
• Check for blood return, then
flush port
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Deaccessing IVAD
•
•
•
•
Use non sterile gloves
Flush with saline and heparin
Remove old dressing
Pull needle out at 90 degree angle
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Blood withdraw
• Stop all infusions and clamp CVAD
lumens for 1 minute prior to drawing
blood or 3 – 5 minutes if parenteral
nutrition is infusing
• Flush line with 10-20 cc NS (no flush
with cultures)
• Withdraw 3 cc discard (12 cc if coag.
studies)
• No discard if taking cultures
• Draw samples in order
• Flush vigorously with 20 cc NS
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Order of tubes to draw
• Blood culture tube
• Coagulation tube (blue)
• Serum tube with or without clot activator or with or
without gel (red)
• SST tube (gold)
• Heparin tube with or without gel plasma separator
(green)
• EDTA (lavender)
• Glycolytic inhibitor (grey)
• For tubes not listed follow local Lab Services guidelines
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Line Occlusion
• Mechanical obstruction – kinked line
• Chemical obstruction – incompatible medications
• Thrombotic obstruction – clot in or around line
• Assessment:
– Fully occluded or sluggish blood return
– Flushes easily, poor blood return
– Chest X Ray
• Attempt to flush with 10 cc NS
– If able, attempt to aspirate blood
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Fibrin Sheath
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Clearing a Blocked Line
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Reconstitution
• Inject 2.2 mL sterile water into vial
• Mix by gently swirling until contents are completely
dissolved. DO NOT SHAKE
• Final concentration will be 1 mg/mL
• Withdraw 2.0 mL (2.0 mg) into a 10 mL syringe
• Inspect product for foreign matter and discoloration
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Administration of Alteplase
•
•
•
•
•
•
•
•
Perform hand hygiene
Don protective gloves
Ensure catheter lumen(s) are clamped
Prior to entering injection cap, cleanse with alcohol,
each time
Attach 10 mL syringe with alteplase
Unclamp the catheter and gently instill the alteplase
Reclamp the catheter if needed, and remove syringe
Label the catheter lumen, "Alteplase 2 mg in place.
DO NOT USE". Indicate date, time & signature.
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Removal of Alteplase
• Leave line in place two hours
• Attempt to aspirate 4-5 mLs of blood
– Flush with 20 mLs NS if able to obtain blood
• If unsuccessful, repeat procedure with second
instillation of alteplase, allowing a dwell time of a
minimum of 2 hours. After dwell time, reassess
catheter function, may require an overnight dwell
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Use of Stopcock for Alteplase
Primed 3-way
stopcock with
injection caps
Turnkey
“off”
To
Lumen
Empty
10 mL
Syringe
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Use of Stopcock for Alteplase
Turnkey
“off” to 10
mL syringe
Turnkey “off”
to Syringe at
6 o’clock
10 mL Syringe Plunger
Withdrawn to Create
Negative Pressure in
Catheter Lumen
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PICC Line Removal
• Reasons for removal of PICC:
– therapy is complete
– infection
– thrombophlebitis
– occlusion (that does not respond to thrombolytic
therapy)
– damage (that cannot be repaired)
– venous thrombosis
– unresolved mechanical phlebitis
– persistent leaking
– the line has migrated
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Warm Compress
• Use of Warm Compress may help induce relaxation
of the veins, and assist with smooth PICC line
removal
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Routine removal
• Grasp the catheter close to the exit site without
applying any pressure to the cannulated vein or
upper arm
• Use a slow, continuous, ‘pulling’ motion to remove
the PICC, keeping the catheter parallel to the skin
• If resistance is felt, never stretch or use excessive
force to remove the catheter which could cause
breakage and possible catheter embolism.
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Routine removal
• While withdrawing the final length of the PICC, hold
the gauze pad lightly over the exit site. Apply firm
pressure to the exit site until all bleeding stops
(approximately 5 – 10 minutes)
• Examine the catheter. Ensure that the tip is intact
Note: If the tip is not intact activate code Blue, if
possible place tourniquet above exit site to occlude
venous return but not arterial blood supply, have
patient sit upright and immobilize arm, treat
signs/symptoms
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Infection suspected
• Obtain swab for C&S if purulent drainage is present
at exit site
• DO NOT allow the tip of the catheter to touch the
skin as it is removed
• With sterile scissors, cut approximately 2 cm off the
catheter tip, ensuring tip does not touch skin. Drop
the tip into sterile container and send to the lab for
culture
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Difficulty with Removal
•
•
•
•
•
Assess for possible causes
Apply gentle tension on the catheter, and tape in place
Wait at least 10 minutes and repeat.
Re-apply new warm compresses to venous pathway,
Provide patient with warm blankets; encourage patient to
drink warm liquids
• Suggest relaxation and distraction exercises (e.g. wrist
and hand exercises)
• Notify physician/NP if catheter removal is unsuccessful
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Complications of CVAD
•
•
•
•
•
•
•
Air embolism
Pneumothorax
Catheter malposition and migration
Catheter occlusion
Damaged or severed catheter
Phlebitis
Infection
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References:
• RNAO best practice Guidelines
• Intravenous Nurses Society (2000). Infusion nursing:
Standards of practice. Journal of Intravenous Nursing
• Oncology Nursing Society. (2004). Access device
guidelines: Recommendations for nursing practice and
education. Pittsburgh: Author.
• Getting a line on CVAD central vascular access devices
Nursing, Apr 2002 by Masoorli, Sue, Angeles, Tess
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•
Recommended Practices for the Prevention of Healthcare Associated
Intravascular Device-related Bloodstream Infections Central Venous
Catheters (CVC) Part I, Queensland Health
• Fibrin sheath formation and chemotherapy
extravasation: a case report Donna Jo Mayo, Supportive
Care in Cancer
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