Vascular Access: Recommended Study Guide PDF

# Vascular Access: Recommended Study Guide for Vascular Access Board Certification ## General Considerations (Umbilical vein catheter) * Follow all manufacturer's instructions for use * Implement maximum sterile barrier precautions * **Supplies:** * Umbilical Vein catheter * Sterile inse...

# Vascular Access: Recommended Study Guide for Vascular Access Board Certification ## General Considerations (Umbilical vein catheter) * Follow all manufacturer's instructions for use * Implement maximum sterile barrier precautions * **Supplies:** * Umbilical Vein catheter * Sterile insertion tray with maximum barrier components * Transparent and/or antimicrobial dressing * **Optimal Tip Location:** * Within the inferior vena cava near the junction with right atrium * **Confirmation of catheter tip location:** * Radiography * Echocardiography * Ultrasonography * Compares favorably to radiography * Injection of NS may aid in identifying tip location * Fluoroscopy * Helpful for difficult bedside placement or patients with congenital cardiac conditions ## Umbilical Artery Catheter * **Indications/Contraindications:** * **Indications:** * Blood Sampling * Continuous blood pressure monitoring * **Contraindications:** * Poor stump condition * Acute abdomen * Omphalitis, omphalocele, necrotizing enterocolitis, peritonitis * Evidence of local vascular compromise in the lower extremities and or buttocks * **Insertion procedure and supplies:** * **General considerations:** * Follow all manufacturer's instructions for use * Implement maximum sterile barrier precautions * Not recommended for infusions of fluids or medications * **Supplies:** * Umbilical Artery catheter * Sterile insertion tray with maximum barrier components * Transparent and/or antimicrobial dressing * **Optimal tip location:** * **High position:** * In the thoracic portion of the descending aorta inferior (below) the aortic arch * Between thoracic vertebrae 6 and 9 on single view chest and abdomen radiograph * **Low position:** * Below/Inferior to the renal arteries and above the aortic bifurcation * Into the common iliac arteries * Between lumbar vertebrae 3 and 4 on single view chest and abdomen radiograph * **Confirmation of catheter tip location:** * Radiography * Echocardiography * Ultrasonography * Fluoroscopy ## Pre-Insertion Considerations ### Site Determination * **Site evaluation:** * The physical exam is an important but an often overlooked portion of the VAD pre-procedural assessment. * **Assess:** * **Skin turgor with emphasis on skin condition at the planned insertion site:** * Presence of any skin lesions, scars, edema, ecchymosis, or grafts in the area of the planned insertion site. * Prominent superficial veins in the area of planned CVAD may indicate neighboring or central vein stenosis or thrombosis. * **Thoroughly assess veins with ultrasound during the assessment:** * Do not use non-compressible or partially compressible target veins as they denote probable thrombosis. * Observe for variance in the vein diameter along the vein pathway which may interfere with catheter advancement. * **Assess for presence of other medical devices in the projected vessel area:** * Tracheostomies, and other VADs. * Check recent CXR for pacemakers or Automatic Implantable Cardioverter Defibrillator (AICD), vascular stents, IVC filters, or other implanted devices. * Assess for barriers to secure dressing application and maintenance such as points of flexion or rotation, other medical devices, excessive hair growth and friction with other body parts such as the medial upper arm and the lateral chest wall. ## Site Selection for Longer Term Devices * Involve patient in decisions related to placement location of an implanted venous port or the exit site of a tunneled venous catheter. * Assess for patient's usual physical, occupational, and recreational activities. * The site selected can be labeled with a surgical marker before device insertion * Consider creative strategies for site location and securement if patient is at high risk for accidental catheter dislodgement, removal, or breakage. ## Pediatric Considerations * Tunneled CVADs are used more frequently in infants and younger patients. * Longer survival of chronically ill children often leads to repeated need for long term vascular access. * Collaboration of medical professionals with family is needed in planning for the appropriate device for vessel preservation * Involve Child Life Specialists with insertion and care procedures. ## Skin Preparation * **Definitions:** * **Antiseptic:** A chemical agent that inhibits microorganisms on skin or tissue and has an effect of limiting or optimally preventing infection. * **Disinfectant:** A chemical agent that destroys microorganisms on inanimate objects * **Properties of ideal skin antiseptic agents:** * Broad spectrum of activity/rapid bactericidal activity * Persistence or residual properties on the skin * Maintain its activity in the presence of organic material * Non-Irritating or have low allergic and/or toxic responses * No or minimal systemic absorption * **Activity and effectiveness of antiseptic solution can be affected by several factors including:** * Pathogenic organism's concentration in that specific area of the skin * Organism's composition * Concentration of the antimicrobial agent * If it is combined with other antiseptic agents (Le, as a tincture with alcohol) * Duration of organism's exposure to the antimicrobial agent * Presence of organic and/or inorganic surface contaminants ## Recommended Agents * **Chlorhexidine Gluconate™** * Chlorhexidine Gluconate (CHG) solution with 70% IPA is preferred by the CDC, IHI, TJC, SHEA/IDSA and other organizations. * Apply to clean skin. Visibly soiled areas should be cleansed with soap and water before disinfectant is applied. * Apply in a back-and-forth motion for a minimum of 30 seconds for effectiveness. * Must be completely dry before needle enters skin and post insertion, before dressing is applied. * **Effective against gram positive, gram-negative bacteria, fungi and viruses.** * Positively charged forms ionic bond with cells to destroy cell wall. * Bonds with proteins in skin providing up to 48 hours residual activity. * Active in presence of organic compounds and inhibits biofilm formation. * **Prep the site and entire area that will be beneath the dressing when used prior to insertion or during care of catheter site.** * CHG is inactivated by soaps and shampoos. Ensure any soap or shampoo is thoroughly rinsed off prior to using CHG * If the femoral area is to be used, application of appropriate skin antiseptic should be applied for at least 2 full minutes using friction and allowed to dry completely. ## Chlorhexidine/Alcohol Prep Applicator Coverage | Applicator Size | Coverage Area in Centimeters | Coverage Area in Inches | |:---:|:---:|:---:| | 0.67 ml | 5cm x 8cm | 2"x3"| | 1.5 ml| 10 x 13 cm | 4"x5" | | 3 ml | 15 x 15 cm | 6"x6" | | 10.5 ml | 25 x 30 cm | 10"x12" | ## Pediatric Considerations * Use with caution in premature infants and children < 2 months of age ## lodophors * Solutions of iodine in complexes that contain a low amount of free lodine * Povidone iodine (Le, Betadine") solutions contain up to 10% of an iodine complex, and provide up to 1% free lodine for skin antisepsis * Alcohol should not be applied after the application of povidone iodine * Tincture of lodine is effective against gram positive and gram-negative bacteria, fungi, and viruses, have minimal effect on bacterial spores