Central Venous Access PDF

Official (Open) CENTRAL VENOUS ACCESS LEARNING OUTCOMES At the completion of this lesson, the students will be able to: 1. State the indications for central venous access. 2. Differentiate vari...

Official (Open) CENTRAL VENOUS ACCESS LEARNING OUTCOMES At the completion of this lesson, the students will be able to: 1. State the indications for central venous access. 2. Differentiate various central venous access devices. 3. State the complications of central venous access. 4. Discuss the principles of care for central venous access. 5. State the indications for central venous access dressing. 6. Demonstrate the care of the patient with central venous access devices. REFERENCES Lippincott’s Nursing Procedures and Skills. (2016). Central venous access catheter insertion, assisting. Retrieved from http://procedures.lww.com.libproxy.nyp.edu.sg/lnp/view.do?pId=1596541&hi ts=inserts,venous,central,catheter,access,insertion,inserted,catheters&a=false &ad=false Lippincott’s Nursing Procedures and Skills. (2016). Central venous tunnelled catheter dressing change. Retrieved from http://procedures.lww.com.libproxy.nyp.edu.sg/lnp/view.do?pId=1596830&hi ts=tunneled,venous,dressing,central,catheter,catheters,dressings&a=false&ad =false Lippincott’s Nursing Procedures and Skills. (2016). Peripherally inserted central catheter (PICC) dressing change. Retrieved from http://procedures.lww.com.libproxy.nyp.edu.sg/lnp/view.do?pId=1596693&hi ts=catheter,dressing,venous,central,dressings&a=false&ad=false Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques (9th ed.). St. Louis: Mosby Elsevier. Perry, A. G., Potter, P. A., & Ostendorf, W. R. (2018). Clinical nursing skills and techniques (9th ed.). St. Louis: Mosby Elsevier. Video on How to Assess CVAD https://www.youtube.com/watch?v=BdgFEcoX61M LEARNING ACTIVITIES Demonstration and practice. Attempt e-quiz exercises in Brightspace (BS). 1 Official (Open) CENTRAL VENOUS ACCESS DEVICES (CVAD) DEFINITION Central venous access devices (CVAD) are small, flexible tubes placed in large veins for people who require frequent access to the bloodstream. It can also be implanted under the skin. INDICATIONS The type of CVC and how it is used will depend on your needs 1. Administration of: − Fluids. − Total parenteral nutrition. − IV fluids or medication e.g., vesicant drugs (e.g. noradrenaline, dopamine, dobutamine, chemotherapy). − Blood or blood products transfusions. − IV therapy in a long-term ambulatory setting or home. 2. Hemodynamic monitoring - central venous pressure (CVP), cardiac parameters. 3. Extracorporeal therapies - Haemodialysis / plasmapheresis. 4. Venous blood sampling. 5. Introducer sheath – Transvenous cardiac pacing, Inferior vena cava filter placement, venous thrombolytic therapy, venous stenting 6. Difficult peripheral venous cannulation. TYPES OF CENTRAL VENOUS DEVICES (CVAD) AND INSERTION SITES. 1. Short-Term devices a. Non-tunnelled percutaneous (non-cuff): i. Type: single, double, triple, quadruple or quintuple lumen, comes in variety of lengths 15-30cm ii. Insertion sites: subclavian, internal jugular and femoral veins. iii. Duration: days to several weeks (depending on the hospital protocol). b. Peripherally inserted central catheters (PICCs): i. Types: Power injectable catheters; single, double or triple lumen ii. Insertion sites: basilic / cephalic vein iii. Duration: as long as they function properly with no intravenous complications (depending on the manufacturer recommendation/ hospital protocol) c. Venous sheath i. Single port and single lumen ii. Duration: days to several weeks (depending on the hospital protocol). 2 Official (Open) 2. Long-Term devices a. External tunnelled (e.g., Hickman, Broviac, Groshong): i. Not sutured, cuffed ii. Types: Open-ended / Close-ended iii. Insertion sites: chest region through subclavian or jugular vein. iv. Duration: permanent unless infected/ complications occur. b. Subcutaneous Implantable venous ports (e.g., Port-a-cath): i. Types: Single/double port or PowerPort (Power-injectable ports for “CT”) ii. Insertion sites: subcutaneous pocket in the chest - below the clavicle (infraclavicular fossa), abdomen, inner aspect of forearm. iii. Duration: Permanent with removal reserved if complications occur or the device is no longer needed (e.g., completion of chemotherapy) Tunnelled catheter Subcutaneous implantable port Dreamstime.com LLC (2000-2019). Dr Daniel Hagley Vascular & Vector drawing of heart, showing endovascular surgeon (2017). subcutaneous tunnel and catheter Portacath insertion. Australia: Brisbane entering superior vena cava. Queensland. Retrieved from Retrieved from https://www.hagleyvascular.com.au/fil https://www.dreamstime.com/stock- e/portacath-insertion photos-drawing-catheter-insertion-heart- vector-showing-subcutaneous-tunnel- entering-superior-vena-cava- image40443213 In triple lumen catheter, it consists of: Distal, medial and proximal port Distal port (Furthest away from the insertion site) – Central Venous Pressure (CVP) monitoring Proximal port Media port 3 Official (Open) Introducer sheath PRINCIPLES OF CARE OF CVC 1) Strict aseptic technique Clean each port with alcohol swabs before use. To swab at least 10 times or 10 seconds (according to hospital protocol). 2) Standard precautions 3) Maintain closed system Use luer lock connections– change every 3 days or following hospital protocol Clamp firmly near to the exit port. Double check clamps and connections. o To prevent air embolism, haemorrhage, infection. Whenever the luer-lock cap is removed from the catheter then it must be replaced with a new one to prevent infection. 4) Maintain catheter patency Avoid interrupted flow during infusion. Ensure adequate and correct flushing technique of central venous access device (Flushing of central venous line to be done by TRAINED STAFF ONLY). After blood withdrawal, flush with 10 mls of normal saline. When not in use, flush with 5mls of heparinised saline (confirm with hospital protocol). Method of flushing: − Push-pause (pulsing method) 1ml at a time and complete with positive pressure technique (this is to prevent blood / fibrin adherence to the catheter lumen wall and tip). 5) Prevent catheter damage Always use 10 ml syringe to flush or administer medications - Smaller syringes increase pressure that causes catheter rupture Avoid using artery forceps on catheter – loosening luer-lock caps Rotate sites of clamping catheter. 6) Prevent and monitor for possible complications Clinical presentations for possible complications 4 Official (Open) - Chest pain / Shortness of breath POSSIBLE COMPLICATIONS Catheter damage/migration Hydrothorax Bleeding Haemothorax Haematoma Pneumothorax Thrombosis Cardiac tamponade Air embolism Infiltration, extravasation Cardiac arrhythmias Infection, sepsis 5 Official (Open) PERFORMANCE CHECKLIST: ASSISTING CENTRAL VENOUS CATHETERISATION ASSESSMENT Review doctor’s order for insertion of CVAD. Identify patient using two identifiers. Assess need for CVC e.g., administration of IV solutions, TPN, extracorporeal therapies. Assess the selected insertion site (decision made by Dr). Assess patient’s understanding of procedure and allergy status. PLANNING Nurse Hand hygiene Environment Ensure privacy. Ensure good lighting. Patient Obtain informed consent Check patient’s coagulation profile - PT/PTT Explain procedure to patient to allay fear and anxiety and gain cooperation Prepare site for insertion: landmarking (done by Dr), shave hair at site of insertion (if necessary) Position: Trendelenburg (if haemodynamically stable) or supine (if unstable). Check allergy status: Lignocaine? Chlorhexidine sensitive? Equipment / Requisites Central venous catheter kit (Bundle) o Central venous catheter insertion set. o Sterile gloves/surgical gown/cap/drape/mask/syringes/needles/ultrasound sleeves. Lignocaine 1%. N/S and Heparin saline for flushing Cleansing solutions per protocol - Chlorhexidine 2% in 70% alcohol or chloroprep stick swab. CVP manometer – if CVP monitoring is required Levelling device (e.g., carpenter ruler) if CVP monitoring is required. Transparent dressing Bed-side ultrasound machine Time out checklist IMPLEMENTATION Hand hygiene and don PPE. Carry out time-out. Prepare site for insertion – expose the area, remove patient’s top, necklace/chain Place protective sheet underneath the selected site 6 Official (Open) For jugular / subclavian placement, place patient in Trendelenburg’s or supine position to prevent air embolism. - Take note: Trendelenburg’s position is contraindicated in patients with head injuries e.g., increased intracranial pressure, spinal cord injuries, respiratory conditions and hemodynamic instability. Ramp position - Place rolled up bath towel between shoulder blades. Ask patient to keep his head turned away from insertion site and not to move during the procedure. Inform patient the need to perform Valsalva manoeuvre (hold breath and strain) upon prompting of doctor (just before time of insertion). Safety: Apply the principles of asepsis in preparing central venous catheterisation set. Assist the doctor as required. Monitor vital signs intra-procedure especially HR. Watch for arrhythmias. Note insertion depth of catheter Dr to check patency of catheter (Aspirate – Saline – Heparin Saline) Apply transparent dressing. CXR to confirm catheter position. Assess vital signs, obtain baseline CVP after verifying correct placement. EVALUATION Give reassurance to patient Monitor vital signs closely Monitor signs of complications -Respiratory status and air entry: − if decreased, suspect pneumothorax or haemothorax -Excessive bleeding over the insertion site. Report and record: − Date, time and site of insertion. − Patients’ tolerance to procedure. − Doctor’s name. − Type of central venous catheter used and depth of insertion (cm marking). − Type of IV fluid used for flushing. − Condition of insertion site − Type of dressing used e.g., Transparent dressing / gauze dressing − CXR to verify proper placement (tip of catheter at SVC or start of the right atrium). – (Verify proper placement first then obtain baseline CVP) − Baseline CVP value. 7 Official (Open) PERFORMANCE CHECKLIST: CENTRAL VENOUS CATHETER SITE DRESSING ASSESSMENT Establish patient’s need for catheter site dressing - Transparent dressings should be changed every 7 days and PRN (following hospital protocol). Refer to nursing care plan for dressing regime Identify patient using two identifiers Assess allergy status to any dressing products PLANNING Nurse Hand hygiene Environment Ensure privacy. Ensure good lighting. Patient Explain procedure to patient to allay fear and anxiety and gain cooperation. Position: supine. Equipment Sterile items: Dressing set, dressing product. Non-sterile items: Gloves, Apron, Protective sheet Appropriate cleansing solution – Chlorhexidine 2% in 70% alcohol or chloraprep swab stick IMPLEMENTATION Hand hygiene, don PPE. Place protective sheet Remove old dressing with gloved hands Note the condition of the insertion site and surrounding skin (intact? redness?) Note the integrity of catheter – length marking (any displacement?) Ensure anchoring stitch holding the central venous catheter is in situ. Surgical handwash or hand rub/ don sterile gloves Prepare dressing set and other requisites using aseptic technique. Begin at insertion site and move outwards in circular motion using antiseptic/chlorhexidine swabs (according to hospital protocol). Allow to dry completely. Apply appropriate sterile dressing and write date changed. Remove gloves and wash hands or hand rub. Note - shave hair surrounding the insertion site to improve dressing adhesion (especially femoral / subclavian approach) 8 Official (Open) EVALUATION Report and record: - Condition of the insertion site and surrounding skin e.g., any redness, discharge, swelling, tenderness or intact. - Notice the length marking on the catheter – any displacement? - Check for catheter integrity e.g., intact or any leakage, breakage or cracked hubs - Date of dressing changed - Ensure no loose connections or kinks on the catheter 9