Vascular Access Procedures PDF

## Non-Thrombotic Occlusion, continued - Alkaline Precipitate with high pH (9-12) may be treated with sodium bicarbonate (NaHCO3) per physician order and institutional policy. - Lipid precipitate/fat emulsions may be treated with 70% ethanol (ethyl alcohol) per physician order and institutional poli...

## Non-Thrombotic Occlusion, continued - Alkaline Precipitate with high pH (9-12) may be treated with sodium bicarbonate (NaHCO3) per physician order and institutional policy. - Lipid precipitate/fat emulsions may be treated with 70% ethanol (ethyl alcohol) per physician order and institutional policy. - Do not flush against resistance. Forceful flushing of a severely occluded CVAD can lead to catheter breakage, catheter embolus, venous thrombosis, catheter-related bloodstream infections, and other serious complications - Improper use, inadequate maintenance care or lack of early detection and intervention can lead to catheter dysfunction that cannot be resolved by means other than catheter removal - Non-Acute Care Considerations - Patients and caregivers should receive ongoing education regarding the importance of early identification of alterations in patency (i.e., sluggish flushing, intermittent or absent blood return), including the need to notify LIP for prompt assessment and intervention" ## P. Management of Ruptured or Broken Catheters - Only the external portion of certain CVADs can be repaired. Use only a manufacturer new hub kit to manage a ruptured or broken catheter. - Causes - Excessive pressure or tension on catheter material during insertion or maintenance. - Forceful flushing practices. - Inappropriate or excessive catheter manipulation. - Improper clamping of or use of sharp instruments near catheter - Prevention - DO NOT remove catheter against resistance - DO NOT flush against resistance - Prevent unnecessary tension on catheter ## Prevention, continued - Use 10 mL or larger syringe (or equivalent barrel size) for all patency checks. The use of a smaller syringe for medication delivery after patency has been established is acceptable. - Avoid use of sharp instruments near catheter such as scissors when performing dressing change. - Use adhesive remover to allow easier removal of transparent dressings and other adhesive materials. ## Symptoms - Damage can present as tear, rupture, or pinhole on the external portion of a catheter. - May manifest as flush or infusate leakage from catheter - Catheter embolus, infection, infiltration, extravasation, and air embolism are potential complications associated with damaged catheters ## Treatment - Notify licensed independent practitioner - Clamp catheter with padded hemostats or non-toothed hemostat between the damaged lumen and patient - Cover the damaged area with sterile gauze or other sterile adhesive material until an assessment of feasibility of repair can be determined and verification that a product specific new hub kit is available from the manufacturer - If a new hub application is possible, only use manufacturer's catheter-specific repair kit and instructions - Determine risks and benefits of hub replacement vs catheter replacement ## Non-Acute Care Considerations - Evaluate and monitor patient for reaction to damaged catheter. If situation becomes emergent, elevate level of care and prepare to transport to acute setting" ## Q. Catheter-Related Bloodstream Infection (CRBSI) - Central Line-Associated Bloodstream Infection (CLABSI) ## Definitions - CRBSI - The most prevalent catheter complication; may occur at insertion or any time during dwell of the catheter and across the continuum of care; CRBSI is a clinical definition used when diagnosing and treating patients, identifies the catheter as the source but not used for surveillance purposes - CLABSI - Is a laboratory-confirmed bloodstream infection (LCBI) where central line (CL) or umbilical catheter (UC) was in place for>2 calendar days on the date of event, with day of device placement being Day 1 and in place on the date of the event or the day before; used for surveillance purposes ## Causes of CRBSI - Inadequate hand hygiene and/or skin prep - Lack of or improper use of maximal sterile barrier precautions (MSBP) during insertion of CVAD - Inherent repopulation of normal skin flora - Contamination of catheter, insertion materials, or maintenance materials - Inconsistent adherence to care and maintenance asepsis. - Immunocompromised patients (i.e., advanced age, premature infants, critically ill, multiple comorbidities) - Immunosuppression therapy - Inadequate cleansing of needleless connector and connections - Administration of contaminated infusate ## Prevention of CRBSI - Strict adherence to evidence based CRBSI prevention guidelines (e.g., maximal sterile barrier precautions for CVAD Insertion, avoid use of femoral vein, use of insertion checklist) - Proper hand hygiene - Prep skin at insertion and dressing change with alcoholic chlorhexidine gluconate >0.5% antiseptic applied with friction. 1% or 2% tincture of iodine, lodophors or 70% alcohol can be for patients with known allergy or sensitivity to chlorhexidine ## Prevention of CLABSI, continued - Application of chlorhexidine-impregnated disc or dressing" - Perform dressing changes per institutional policy - Avoid routine use of gauze dressings - Disinfect the needleless connector, injection port or catheter hub using a friction scrub using 70% Isopropyl alcohol or alcoholic chlorhexidine gluconate solution prior to each access. - Consider the use of passive disinfection caps containing 70% IPA. Use of such caps should be according to the manufacturer's instructions for use and does not replace need for friction scrub of needleless connector prior to each access. - Consider use of a chlorhexidine/silver sulfadiazine or minocycline/rifampin impregnated CVAD in patients whose catheter is expected to remain in place for 5 days if CLABSI rates are not decreasing after successful implementation of a comprehensive strategy to reduce rates of CLABSI - Consider an antimicrobial lock solution for patients with long-term catheters and diagnosis of CRBSI with no signs of exit site or tunnel infection, and for whom catheter salvage is the goal. - Assess need for each catheter daily and promptly remove unnecessary CVADs and peripheral IVs. ## Symptoms of CRBSI - Signs of sepsis (e.g., hypotension, tachycardia, fever, chills, pain, malaise, elevated white blood cell count, or confusion) - Note: Purulent drainage or erythema at site may not be present and may not directly correlate with evidence of CRBSI ## Treatment of CRBSI - Rule out other possible sources of infection (consider time-to-positivity blood cultures to confirm/rule out catheter as source) - Blood cultures and antibiotic therapy may be indication per provider order - Removal of CVAD may not be indicated if appropriate antimicrobial therapy can be effectively administered - Infection of an implanted port may require surgical removal ## Non-Acute Care Considerations for CRBSI - Patients should be assessed for signs of CR-BSI at every encounter. - Patients and caregivers should be educated regarding the signs, symptoms, and rationale. If CR-BSI is suspected in Non-Acute Care Settings, notify LIP for further orders prior to using CVAD or changing dressing, as paired blood cultures and/or cultures of purulent exudates may be ordered.