Central Venous Lines (PDF)

Central Venous Lines (aka central venous access device or central venous catheter) Uses: - Peripheral access is unobtainable - Long-term infusion therapy - Hemodynamic monitoring (cardiovascular pressure monitoring) - Large volume or fluid/blood to be given - Caustic a...

Central Venous Lines (aka central venous access device or central venous catheter) Uses: - Peripheral access is unobtainable - Long-term infusion therapy - Hemodynamic monitoring (cardiovascular pressure monitoring) - Large volume or fluid/blood to be given - Caustic agent administration Types: 1. “Short” Non-tunneled Catheter a. Insertion: bedside by MD or specialty-trained RN with needle + guidewire i. Location: percutaneous in internal jugular (neck), subclavian (chest) b. Uses: immediate access for emergency, can have multiple lumens/ports c. Risk: higher infection/complication risk d. Short-term (1-2weeks) 2. Non-tunneled Peripherally Inserted Central Catheter (PICC) a. Insertion: bedside by MD or specialty-trained RN with needle + guidewire i. Location: basilic or cephalic (arm) b. Uses: can have multiple lumens/ports c. Risk: neurovascular compromise of extremity (from nerve puncture), increased thrombosis, catheter shearing d. Long-term (can last 12months) 3. Tunneled Central Catheter a. Insertion: OR or interventional radiology i. Location: b. Uses: dacron cuff, can have multiple lumens/ports c. Notes: clamp anytime not in use; flush daily when not in use d. Permanent (months-years) 4. Implanted Port a. Insertion: surgical implantation i. Location: subcutaneous pocket b. Uses: can have 1 or 2 lumens/ports, consists of dense silicone septum with steel reservoir, need non-coring needle (Huber Needle), flush every 4 weeks not in use c. Permanent (months-years) Insertion Protocol – Short Non-tunneled Catheter 1. Positioning: a. Trendelenburg, high bed position, rolled towel between shoulder blades, head to the side 2. Nursing role: open supplies and drop onto tray/sterile field; position head, comfort patient; talk patient through procedure 3. Complications:  a. Pneumothorax, nerve injury, cannulation of wrong vessel, catheter dislodgement, phlebitis, thrombosis b. Mispositioned catheter -> advance further or pull back c. Air embolism -> put patient on left side with feet up, give O2, monitor status d. Arterial puncture -> remove, apply pressure 10-15min, attempt on other side i. you will see bright red, pulsating blood e. Infection i. Causes: non-occlusive dressing, poor technique with dressing changes, poor hand washing, secretions ii. -> discontinue catheter, cut off catheter tip and culture f. Catheter rupture i. Causes: excessive force in flushing, catheter compression (pinch-off syndrome) ii. -> if you meet resistance, pull back and see if blood returns Blood Draw Protocol 1. Apple tourniquet, palpate vein, clean site 2. Hold skin taut, insert bevel up @ 15-30 degrees 3. Feel pop/see flash 4. Hold syringe securely and pull back gently on plunger or allow vacutainer to draw a. For vacutainer: rotate each tube 8-10x to mix blood with additives in tube 5. Release tourniquet, apply 2x2 gauze with pressure and withdraw needle Medication Administration IVP Protocol 1. Prime new cap with normal saline 2. Scrub area where cap detaches from catheter 3. Attach new cap (that is attached to normal saline syringe) 4. Assess for blood return 5. Administer normal saline flush (5-10mL) with push-pause method 6. Administer medication with push-pause method 7. Administer normal saline flush (5-10mL) with push-pause method a. Clamp + remove flush 8. Scrub hub and administer heparin flush 9. Clamp end and remove heparin syringe Dressing Change 1. Position patient with head turned away from insertion site 2. Hand hygiene, mask for nurse and patient, clean gloves 3. Assess site, remove clean gloves -> open CVAD kit and apply sterile gloves 4. Scrub site with chlorhexidine solution for 2mins (horizontal, vertical, circle scrubs) 5. Use skin prep and apply new stabilization device 6. Apply transparent semipermeable membrane dressing with label Removal Protocol “Short” Non-tunneled Catheters: 1. Clip suture or remove stat-lock 2. Positioning: a. HOB flat or Trendelenburg b. Perform Valsalva maneuver (hold breath, hum, bear down) to prevent air embolism 3. Remove steadily 4. Hold pressure for 10mins, if still bleeding apply pressure for 5min and recheck 5. Apply dressing 6. Inspect removed catheter, measure length of catheter, and document PICC: 1. Hot pack to area for 10-15mins (dilate vessels and minimize venous spasms) 2. Clean gloves -> remove dressing and stat-lock 3. Positioning: a. Supine with HOB stop, tell patient to relax, use hot pack, and reattempt in 1-2mins 5. Hold pressure for 10mins and apply dressing 6. Inspect removed catheter, measure length of catheter, and document Other Notes about CVLs: - Central Line Bundle o Chlorhexidine bath Q24h -> decrease infection risk o Assess dressing Q24h -> make sure dry/intact or change  Change Q7days (or 24h after insertion) or when soiled o Disinfectant caps on -> create closed system w/alcohol  Changed Q72-96h o Assess label on tubing, dressing, bags -> change out as required  IV solutions changed Q24h  IV tubing changed Q72-96h o Review need for CVL Q24h o Biopatch to keep antiseptic near port - De-clotting CVLs: o t-PA or low dose alteplase  after 2h, 75% patency restored  second dose restores 85% patency - Fibrin Sheath and Tails o If improperly maintained, clot will form at end of catheter -> a fibrin sheath or tail can cover exit ports and the render the catheter unusable   It won’t allow blood to return (because sheath covers) but it may flush easily because ‘tail’ lifts up - Nursing Considerations o Only use 10mL syringe or larger (smaller syringes have too much pressure) o Use push-pause method when flushing (allows blood to flush and prevent clots) o Scrub the hub for 15-30secs o Disinfection caps on when ports are not used o No BP or venipunctures in arm with a PICC