CVADs
Dressed and cared for like a central line with sterile dressings but is a peripheral catheter placed by specially trained person in one of the larger veins of the upper arm, with the catheter tip terminating below the axilla.
Are appropriate for short-term use, usually lasting 2 to 6 weeks
Midline Catheter
Often used to deliver IV medication because they minimize fluid requirements and more precisely deliver small volumes of medication compared with large-volume infusion pumps.
Syringe pumps
Specialized volume controlled IV infusion device may also be used (common brand name-Burette by Braun)
One of the most effective ways to maintain catheter patency
Flushing
If flushing one lumen- flush them all to prevent occlusions.
Two of the most common complications of central venous catheters.
Infection and catheter occlusion.
They require treatment with antibiotics for infection and a fibrinolytic agent, such as alteplase, for thrombus formation.
Signs of Catheter Migration due to
• Improper suturing
• Insertion site trauma
• Changes in intrathoracic pressure
• Forceful catheter flushing
• Spontaneous
• Sluggish infusion or aspiration
• Edema of chest or neck during infusion
• Patient reports gurgling sound in ear
• Dysrhythmias
• Increased external catheter length
Management of complication
• Prepare for fluoroscopy to confirm position
• Assist with removal and new CVAD placement
Type of central line used in acute care, emergency, and intensive care units. Made of polyurethane and are placed in large veins, such as the subclavian, femoral, or jugular. Insertion is by surgical incision or large percutaneous threading. Chest radiograph is taken to verify catheter tip is properly located in a large central vein before administration of fluids or medications.
Short - term or non-tunneled catheters
Reasons for use of a central venous catheter in pediatric population. (name 2)
Children with acute or chronic illnesses who require repeated blood sampling; medications; long-term chemotherapy; in intensive care; require frequent hyperalimentation or require frequent antibiotic therapy.
Size of syringe used to flush a central line
Use a normal saline solution in a syringe that has a barrel capacity of 10 mL or more to avoid excess pressure on the catheter. If you feel resistance, do not apply force. This could result in a ruptured catheter or create an embolism if a thrombus is present.
Because of the risk for contamination and infection, use solution from prefilled syringes or single-dose vials rather than multiple-dose vials when flushing catheters. If you are not using a positive-pressure valve cap, clamp any unused lines after flushing.
Advantages of CVADs
Provide immediate access to the central venous system; a reduced need for multiple venipunctures; decreased risk for extravasation injury; permit frequent, continuous, rapid, or intermittent administration of fluids and medications.
Ability to administer more safely potential vesicants, blood and blood products, and Parenteral Nutrition.
Provide a means to perform hemodynamic monitoring, obtain venous blood samples and inject radiopaque contrast media.
Signs of Catheter related infections due to:
• Contamination during insertion or use
• Migration of organisms along catheter
• Immunosuppressed patient
• Local: redness, tenderness, purulent drainage, warmth, edema
• Systemic: fever, chills, malaise
Management of complication
• Culture drainage from site
• Apply warm, moist compresses
• Remove catheter if needed
Systemic
• Take blood cultures
• Give antibiotic therapy
• Give antipyretic therapy
• Remove catheter if needed
Central line used for short-term to moderate-length therapy. Consist of silicone or polymer material and are placed by specially trained nurses, physicians, or interventional radiologists. Most common insertion site is above the antecubital area using the median, cephalic, or basilic vein and is threaded either with or without a guidewire into the superior vena cava. Radiology confirmation is needed before use.
Peripherally inserted central catheters (PICCs)
Preferred central line dressing
Transparent dressings -they allow observation of the site without having to remove the dressing. Transparent dressings may be in place for up to 1 week. Change any dressing at once if it becomes damp, loose, or soiled.
Before manipulating a catheter for any reason, perform hand hygiene. Perform dressing changes and cleanse the catheter insertion site using strict sterile technique. Other typical dressings include transparent semipermeable dressings or gauze and tape. If the site is bleeding, a gauze dressing may be used but is changed to transparent dressing usually within 24 hrs.
Included in assessment before flushing of a central line
Assess for presence of infection, bleeding, and for dry and intact dressing. Blood return should be observed before injecting into central line.
An x-ray to confirm placement is needed post placement and before first use of the central line.
Advantages of a peripherally inserted central catheter (PICC) over a Central Venous Catheter (CVC)
Lower infection rate, fewer insertion-related complications, decreased cost, and ability to insert at the bedside or in an outpatient area.
Signs of catheter occlusions due to
• Clamped or kinked catheter
• Tip against wall of vessel
• Thrombosis
• Precipitate buildup in lumen
• Sluggish infusion or aspiration
• Inability to infuse and/or aspirate
Management of complication:
• Have patient change position, raise arm, and cough
• Assess and alleviate any clamping or kinking
• Flush with normal saline using a 10-mL syringe. Do not force flush
• Instill anticoagulant or thrombolytic agent
Silicone, radiopaque, flexible catheter with open ends or VitaCuffs (biosynthetic material impregnated with silver ions) on catheter(s) enhance tissue ingrowth
May have more than one lumen
After the site heals, the catheter does not need a dressing, making it easier for the patient to maintain the site at home.
Tunneled Catheter (e.g., Hickman or Broviac Catheter)
Cleansing agent of choice used with dressing changes.
A chlorhexidine-based preparation is the cleansing agent of choice. Its effects last longer than either povidone-iodine or alcohol, offering improved killing of bacteria. Cleansing the skin with friction is critical to preventing infection. Cleanse the skin around the catheter insertion site according to agency policy. When applying a new dressing, allow the area to air dry completely. Secure the lumen ports to the skin above the dressing site. Document the date and time of the dressing change and initial the dressing.
Technique used to flush central line catheters
Use the push-pause technique when flushing all catheters. Push-pause creates turbulence within the catheter lumen, promoting the removal of debris that adheres to the catheter lumen and decreasing the chance of occlusion. This technique involves injecting saline with a rapid alternating push-pause motion, instilling 1 to 2 mL with each push on the syringe plunger.
Disadvantages of a peripherally inserted central catheter (PICC) over a Central Venous Catheter (CVC)
PICCs have an increased risk for deep vein thrombosis and phlebitis.
If phlebitis occurs, it usually happens within 7 to 10 days after insertion. Do not use the arm with the PICC to take a BP reading or draw blood. When the BP cuff is inflated, the PICC can touch the vein wall, increasing the risk for vein damage and thrombosis.
Signs of embolism due to:
• Catheter breaking
• Dislodgment of thrombus
• Entry of air into circulation
• Chest pain
• Respiratory distress (dyspnea, tachypnea, hypoxia, cyanosis)
• ↓ BP
• ↑ Pulse
Management of complication:
• Apply O2
• Clamp catheter
• Place patient on left side with head down (air emboli)
• Notify provider
Implantable metal or plastic device lies in a surgically created subcutaneous pocket on the upper chest or arm. Consists of a titanium or plastic reservoir covered with a self-sealing silicone septum with a preconnected or attachable silicone catheter that is placed in large blood vessel
Access the port by using a special non-coring needle with a deflected tip which prevents damage to the septum
Implanted Ports (e.g., Port-a-Cath, Infuse-a-Port, Mediport, NorPort, Groshong Port)
Used to disinfect catheter hubs, needleless connectors, and injection ports before accessing the catheter.
Alcoholic chlorhexidine preparation, 70% alcohol, or povidone-iodine per agency policy.
Change injection caps at regular intervals according to policy, or if they have damage from excess punctures. Use strict sterile technique. Teach the patient to turn the head to the opposite side of the insertion site during cap change. If you cannot clamp the catheter, have the patient lie flat in bed and perform the Valsalva maneuver whenever the catheter is open to air to prevent an air embolism.
Technique when using a negative-pressure cap or neutral pressure cap when flushing the central line.
If you are using a negative-pressure cap or neutral pressure cap, clamp the catheter while maintaining positive pressure while instilling the last 1 mL of saline. This prevents reflux of blood back into the catheter.
If a positive-pressure valve cap is present, it works to prevent the reflux of blood and resultant catheter lumen occlusion.
Remove the syringe before clamping the catheter to allow the positive pressure valve to work correctly.
Advantage of implanted port central line
Good for long-term therapy and have a low risk for infection. The hidden port offers the patient cosmetic advantages and overall has less maintenance than other types of CVADs. Monitor for infiltration that can occur if the needle is not in place or dislodges.
Signs of pneumothorax due to:
• Perforation of visceral pleura during insertion
• Decreased or absent breath sounds
• Respiratory distress (cyanosis, dyspnea, tachypnea)
• Chest pain
• Distended unilateral chest
Management of complication:
• Apply O2
• Place in semi-Fowler’s position
• Prepare for chest tube insertion