Transcript Infusion Therapy - Faculty Sites

Infusion Therapy
Metropolitan Community College
Fall 2013
Jane Miller
Infusion Therapy
• PARENTAL – the gastrointestinal
system is by-passed
–Medications and solutions are
delivered by Intravenous (IV) routes
–Non-vascular routes - (i.e. Subcutaneous (SQ), Intramuscular
(IM), Intraosseous (IO), Intraspinal, or
Intrathecal routes.
Vascular Access Device (VAD)
• Device or catheter introduced through the skin
and into the vascular network.
– Peripheral Vascular Access Devices (PVAD)
• Inserted in upper extremities and/or lower extremities
– Central Vascular Access Devices (CVAD)
• Inserted into a Centrally or Peripherally Located Vein with
the tip residing in the vena cava
Vascular Access Devices (VAD)
• Bevel – the slant or angle at the end of the needle
• Insertion is Bevel up – facilitates puncture and cannulation
of the vascular lumen.
• Flashback chamber – small space in the hub of
the stylet that allows confirmation of the
presence of blood and indicated access to the
vascular lumen
• Self-sheathing stylet - the needle to becomes
encased in a protective chamber upon removal
Images of IV Catheters
Needle Stick Prevention
Types of Peripheral Access Devices
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Winged Steel
Over-the-needle Peripheral Short Catheters
Through-the-needle Peripheral Short Catheters
Midline Catheters
Peripheral Vascular Access Devices
(PVAD) –Peripheral-Short Catheters
• Most - < 7.5 cm (3.5 inches) in length and Gauge
(needle size) 25 (smallest) to 10 gauge (largest).
• Locations of insertion and length of insertion
time:
– Inserted in upper extremities mostly (lower
extremities - per policy) of adults patients.
– Pediatric patients – insertions are upper extremities,
occipital, superficial temporal, posterior auricular(ear)
and saphenous veins.
– Dwell times are 72 to 96 hours, in most cases.
Short Catheter Sizes
Common Peripheral IV Stick Sites
Winged Steel Infusion Set
• Winged Steel – flexible plastic attachments “wings”
that extend from either side of the steel needle to
facilitate insertion.
– Length – 3/8 to 1.5 inches
– Gauges – 19 to 27 gauge
• Attached to the needle is plastic tubing extending from
several inches to 12 inches with an adaptor attachment
on the end for infusion administration equipment.
• Manufactured with safety sheaths.
• Complications – infiltration - due to needle rigidity
• Temporary / short term infusions < 4hours – supportive
devices – arm boards/splints
Winged steel infusion set
Over-the-needle and Through-theneedle Peripheral Short Catheters
• OVER-THE-NEEDLE – MOST COMMON
– Hollow bore needle (stylet) – inserted through the
lumen of a flexible catheter – needle (stylet) is
then withdrawn as the flexible catheter is
advanced forward into the vein
• THROUGH-THE-NEEDLE
– Allows passage of a catheter through a steel
introducer – introducer needle is then withdrawn
from the vessel lumen-and then protected by a
cover or sleeve to prevent sheering or patient
injury
Through-the-needle short catheter
Complication-catheter shearing
Peripheral VAD - Midline
• Peripherally inserted but is approximately 7.5 cm to 20 cm
(3.1 inches to 8.0 inches)
• Longer dwell periods but not to exceed 4 weeks
• Insertion sites –
– Adults - antecubital fossa
– Pediatrics – antecubital fossa, saphenous, posterior auricular
(ear) superficial temporal
• Distal tip – dwells in basilic, cephalic, or brachial veins –
level with the axilla and distal to the shoulder
• Inserted using an introducer-once vein is canulated the
needle (stylet) is withdrawn and the midline catheter is
threaded though the introducer –then introducer is
peeled apart or separated and withdrawn.
• Therapies for midlines-restricted to pH 5-9, osmolarities of
<500mOsm/L
Peripheral IV Catheter
Insertion/Removal
• RN’s, LPN-C – trained in IV insertion using standard
precautions and aseptic technique, RN’s only can be
specially trained to insert midlines.
• RN’s, LPN-C and LPN – trained in IV removal using
standard precautions and aseptic technique
• Assess/observe for phlebitis, drainage-apply sterile
dressing till hemostasis is observed.
• Inspect cannula, for midline – length of catheter
should be measured and be same length as
insertion.
CENTRAL VASCULAR ACCESS DEVICE
(CVAD)
• Catheter inserted into a centrally located vein
with the tip in residing in the vena cava.
• Tip in vena cave must be confirmed with
radiologic examination (X-Ray)
• Three major CVAD Categories
– Nontunneled and noncuffed
– Tunneled and cuffed
– Implanted Ports
Nontunneled and Noncuffed CVAD
• Inserted percutaneuosly via direct skin puncture with passage
of catheter into the vasculature.
• Single or multiple lumens
• Indentified by insertion site (i.e. – Subclavian, Jugular,
Femoral)
• Inserted by physicians or advanced practice clinicians
• Insertion requires – sterile technique and maximum barrier
precautions
• Complications – pneumothorax, air embolism, arrhythmias
• Once inserted secured – sutures, stat locks
• Catheters are not tunneled under the skin – less dwell times
than tunneled
• Examples – TRIPLE LUMEN NONCUFFED (ARROW)
Removal of Nontunneled and
Noncuffed CVAD’s (including PICC)
• May be done by a nurse skilled and educated in the
procedure
• Standard precaution and aseptic technique
• Recumbent position (preferred)
• Removal of occlusive dressing and securing devices
• Instruct Patient to perform the valsalva maneuver to prevent air from entering – causing air embolism
• Pressure is applied 30 minutes to achieve
hemostasis and sterile occlusive dressing applied
• Post removal catheter length measured and
compared to insertion length (same)
Nontunneled noncuffed CVP – Triple
Lumen (Arrow)
Peripherally Inserted Central Catheter
(PICC)
• Nontunneled and non cuffed
• Long-term catheter – several weeks to one year.
• Therapies with extreme variations in solution pH (>5 and <
9) and osmolarities >600 mOsm/L with irritant and Vesicant
properties
• Therapies – Total Parental Nutrition (TPN), Antineoplastic,
Anti-infective and Inotropic
• Radiologic confirmation (X-Ray) required for tip location –
vena cava
• Complications – device fracture, tip malposition, device
occlusion, thrombus formation
• Removal – same as central insertion central venous access
devices
PICC vs. Midline
Tunneled and Cuffed CVAD
• Cuff – piece of the catheter for stabilization and
reduces migration of organisms
• Anti-thrombogenic catheters
• Tunneled under the skin – reduces infection risk
• Inserted in surgical or radiologic suite
• Inserted by physicians, surgeons, vascular surgeons and
advanced practice clinicians trained in procedure
• Long term therapies
• Single or multi-lumens
• Examples: Broviac, Hickman, Raaf, Groshong
Implanted Ports
• Long term – chronic therapies
• Chambered device, double or single reservoirs with an
attached single or double lumen catheter
• Catheter tip dwells in a designated structure depending on
therapy – could be vascular or non-vascular (CVAD PORTS –
Vena Cava)
• Inserted by physicians, surgeons, vascular surgeons and
advanced practice clinicians trained in procedure in a
surgical or radiological suite
• The septum is the access point-damage to the septum could
cause air embolism, infiltration, extravasion, infection
• Access of septum of port requires a noncoring (Huber
needle) needle with opening on the side and preventing
coring of the septum
• Therapies – antineoplastics, inotropics, TPN, Antibiotics
Additional Info on VAD’s
• Tunneled and cuffed and Implanted port
removal only by physicians, advanced
clinicians trained in procedure and not
included in the scope of practice for nurses
• CVAD – Lines flushed and patency checked q
shift with 10ml of Normal Saline (Heparin per
institution) whereas PVAD’s are flushed and
checked for patency q shift with 3-5 ml
Normal Saline.
SPECIALIZED INFUSION CATHETERS
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Hemodynamic Monitoring – Swan Ganz
Dialysis and Pheresis Catheters
Arterial – Venous Shunts
Arterial Catheters
Hepatic Artery Catheters
Swan-Ganz Catheter
• Exclusively for cardiac monitoring and
hemodynamic analysis
• Used to measure
– Central Venous Pressure (CVP)
– Pulmonary Artery Pressure (PA)
– Cardiac Output (CO)
– Pulmonary Artery Wedge Pressure (PAWP)
– Temporary Pacing
– Parental Therapy Administrations
Swan-Ganz Catheter
Hemodialsys and Pheresis Catheters
• RARELY considered for infusions
• Used for procedures using large amounts of blood –
Dialysis, Plasmapheresis, Aquapheresis
• Dialysis Catheters – temporary till a shunt can be placed
• Catheters are large (12 to 16 G) for blood to flow in both
directions on dialysis or pheresis machine, dwell in the
vena cava
• Surgical Placement – OR, Radiological suite or at bedside
by vascular or general surgeon or advanced practice
clinician trained in procedure
• Examples – Quinton, Hohn, Tesio, Perma-Cath, and
Trialysis* *(Trialysis-can be used for infusions)
Dialysis and Pheresis Catheters
Arterial-Venous Shunts
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Anastomose venous and arterial structures
Arm – radial and cephalic and brachial veins
Dialysis or large blood volume exchanges
Accessed with large bore needle
Can be used for other infusion- rare
Patency assessed by auscultation bruit and
palpating vibration
• No IV sticks, phlebotomy or Blood Pressure on
Arm with AV Shunt
• If AV shunt is damaged – only surgical repair or
replacement is the option
AV Shunt and AV Graft
Arterial Catheters
• Used for ONLY two reasons:
– Invasive Blood Pressure Monitoring
– Blood Draws
• Catheters are made of stiff polyurethane material
to withstand the high pressure of the artery and
blood pressure monitoring attached to pressure
transducers and monitor, and to limiting kinking
of line.
• Inserted in Radial or Femoral Arteries
• Inserted by physician or advanced practice
clinician in OR, or Radiological suite or at
bedside.
Arterial Catheter
Hepatic Artery Catheters
• Specialized Catheter Inserted in Hepatic Artery
• Only for regional anti-neoplastic therapy for
Liver Cancer Patients
Hepatic Artery Catheter
NONVASCULAR ACCESS DEVICES
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Subcutaneous Infusion Therapy
Intraosseous Therapy
Intraspinal Catheters
Intrathecal Therapy
Subcutaneous Infusion Therapy
• Hypodermoclysis – infusing large amounts of isotonic
solutions in the subcutaneous to be absorbed
• Continuous Subcutaneous Infusion – infusing small amounts
of medications like pain medications and insulin
• Use very small gages of 25-27G and only ½ inch in length
• Needle attached to a adhesive disk of may appear as a
winged steel infusion set
• May be inserted by a nurse in locations of adequate
subcutaneous tissue
• Site is prepared with antiseptic agent, allowed to dry and
then aspirated to confirm absence of blood
• Device is then secured with sterile dressing
• Complications – localized skin irritation, erythemia, itching,
infection and dislodgement of device
Subcutaneous Infusion Pump
Intraosseous therapy
• Insertion of hollow bore needle into the bone
accessing the marrow space
• Screws into long bones of the leg, iliac crest or
sternum
• Allows for rapid infusions of large volumes of
fluids
• Complications – bone fracture, infiltration,
osteomyelitis, cellulitis, occlusions, or needle
breakage
• Ideal for patients with difficult venous access
• Being used more by EMT, Paramedics
INTRAOSSEOUS
Intraspinal Catheters
• Catheters inserted within the spinal spaces – epidural and
intrathecal
• Delivery of anesthesia and infusions
• Diagnostic testing
• 22 to 26 Gauge, 10 to 30 inches in length
• Catheter inserted percutaneously or tunneled
• Infusates, drugs and diluents must be preservative free due
to neurotoxic effects
• Epidural space usually cannot accommodate infusion rates
greater 15ml/min
• Cross the dura mater and have direct effect on the CNS
• Complications: malposition and infection
• Sterile technique required
• Usually inserted by anesthesiology or neurology
Intrathecal Therapy
• Administration of medications directly into the
Cerebral Spinal Fluid via an implanted reservoir
• Catheter dwells (terminates) in the ventricular
space of the cerebrum
• Ommaya Reservoir
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Delivers preservative free opioids
Antineoplastics
Measures CSF pressures
Drains excess CSF
Obtaining CSF samples for Lab
Surgically places via burr hole in the skull and skin
secured over the device
– Standard precautions and sterile technique
INFUSION DELIVERY
Fluid Containers
• Glass
– Can be heavy
– Requires venting
– Accurate to measure
• Plastic
– Portable, easy to store, inexpensive
– Flexibility may cause volume and dosage
administration to vary
Administration Sets
• The tubing that delivers fluid from the
container to the catheter
• Primary set = main tubing
• Secondary set = tubing that attaches to the
primary set (piggy backed on the primary set)
• Metered-Volume Chambered Set – neonates
and pediatric patients and critical care units
for close observation and monitoring with
fluid control issues
Primary set with
Secondary (Piggy back Set)
Add On Devices
– Flow-control device – controls flow when used
with gravity IV set
– Stopcocks – manually directs flow
– Extension sets – adds length to tubing, provides
additional stopcocks, access sites
– Multi-flow adaptors and Y sets – multiple access
on one catheter
– Injection ports, caps or hub – sites for IV catheter
access
– Filters – remove particulate, precipitate
ADD ON DEVICES
Flow Control Device
Stopcock
Add On Devices
Extension Set
Multiflow Adaptor
Odd On Devices
Injection Port or Cap
Filter
INFUSION DELIVERY DEVICES
• Mechanical infusion devices (MIDs)
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Do not require an external power source to operate
Elastomeric Balloons (On Q)
Spring coil containers
Spring Coil Syringes
• Electronic infusion devices (EIDs)
– Do require an external power source
– Two types: pumps (positive pressure) and controllers
(gravity and drop sensors attached to drip chamber)
Positive Pressure Infusion Pumps
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Pressure to overcome vascular resistance
Strict monitoring of medications, fluids
Accurate delivery
PUMP TERMS:
– RATE (R) – amount of ml/hr
– Volume to be infused (VTBI) – volume of infusion
– Volume Infused (VI) – volume that has already been infused
(Used when calculation I&O)
• Alarms:
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AIR IN LINE
OCCLUSION (patient side or pump side)
INFUSION COMPLETE
FREE FLOW
OTHER – LOW BATTERY, DOOR OPEN, PUMP Malfunction
Patient Controlled Analgesia Pumps
(PCA)
• Delivers analgesia medications continuously
(basal rate)
• Delivers analgesia bolus on patient demand
(PCA Mode)
• Time lockout and Maximum Dose settings for
safety
Before Starting Infusion
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Informed consent
Order
Competent and proficient
Patient assessment
Perform hand hygiene
Select the site
Perform site preparation
After Starting Infusion
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Secure the catheter
Apply a dressing
Flush the line
Document the procedure
Managing Infusion Complications
Complication categories:
• Local complications: Bruising, Infiltration,
Extravasation, Phlebitis, Thrombosis,
Infection, Occlusion
• Systemic complications: Air embolism,
Catheter embolism, Pulmonary edema,
Septicemia, Allergic reactions
Resources
• Osborn, Wraa, & Watson chapter 22