CVAD Information PDF

Indication for CVAD use: 1. Clinical instability of patient a. Low BP b. Signs of shock c. Multiple medications 2. Prescribed continuous or intermittent infusion therapy a. Hemodilution of vesicant solutions i. Chemo...

Indication for CVAD use: 1. Clinical instability of patient a. Low BP b. Signs of shock c. Multiple medications 2. Prescribed continuous or intermittent infusion therapy a. Hemodilution of vesicant solutions i. Chemo ii. Dopamine b. Hemodilution of irritating medications/solutions i. Hypertonic solutions ii. TPN iii. Dextrose iv. Phenytoin 3. Hemodynamic monitoring (measuring pressure) 4. Documented hx of difficult peripheral venous access CVAD Catheter Models: 1. Non Groshong (ㅁ): tip is open a. Required clamping b. NS or heparin flush to maintain patency 2. Groshong (🈩): closed tip with slit that works like 2 way valve a. NO clamps b. NS to maintain patency 3. Single or multi-lumen: a. Multi-lumen: each lumen has distinct port/channel/outflow site- incompatible meds CAN be infused at same time without mixing 4. Triple Lumen: (most common) a. Proximal lumen: 18g, best for blood draws b. Medial lumen: 18g, sometimes used for TPN c. Distal lumen: 16g, high volume use Insertion Sites: 1. Subclavian vein: a. “Preferred vein” due to decreased infection rate b. Close to lung apex, moves with respirations c. Reaches SVC 2. Internal jugular: a. Higher infection rate b. Large vessel, easy access, harder to immobilize, mechanical occlusion when head is turned c. Decreased RF thrombosis (further from lung) 3. Femoral vein: a. Increased RF complications  b. Only for short term emergencies c. Reaches IVC Nursing Care: Use 10ml (NO smaller) pre filled syringes for flushing Change needleless connectors Q96 hr or if blood administered/drawn through cap Every shift: ○ Assess risk/benefit of CVAD ○ Check blood return and flush until.5ml left in syringe ○ If fluids running, check for blood return with each bag and tubing change ○ Site assessment ○ Skin asepsis Scrub the hub 10 sec, let dry 5 sec and use Curos caps 20 ml flush before and after TPN or blood draws Change IV tubing every 96 hours continuous or 24 for intermittent (off the port and putting cap on) Change dressing every 7 days or as needed Change end injection caps/ports every 96 hours/with blood draws/blood admin/TPN If NO blood return, DO NOT use port ○ First try changing connector ○ Document, report, inform IV therapy Tip Placement: EKG, ultrasound, or Xray to confirm tip placement MUST BE obtained prior to using CVAD Documentation of tip needs to be available in healthcare record Tip Placement Locations: 1. Cavoatrail junction of SVA: a. Greatest safety profile b. Blood flow = 2,000ml/min c. Decreased RF complications 2. Distal SVC: a. More commonly noted in X Ray 3. Mid SVC a. Okay 4. Upper SVC a. Okay: More RF thrombosis 5. Thoracic IVC a. When femoral CVAD is placed Tip Placement you MAY NOT use CVAD: 1. Right atrium a. RF dysrhythmias/cardiac tamponade/perforation 2. Subclavian a. RF venous thrombosis 3. Brachiocephalic (Innominate) a. RF venous thrombosis 4. Jugular a. RF venous thrombosis 5. External or internal iliac veins Complications: Immediate comps of CVAD insertion: ○ Pneumothorax, hemothorax, hydrothorax, chylothorax ○ Cardiac tamponade ○ Air embolism IF it occurs, turn pt on their L side in Trendelenburg position and administer high flow O2 ○ Catheter malposition ○ Nerve or vascular damage Delayed or long term comps of CVAD insertion: ○ Central line associated bloodstream infection (CLABSI) Lab confirmed bloodstream infection where a central line was placed for greater than 2 days and no other source of infection found RF: Prolonged hospitalization Prolonged central venous catheterization Heavy microbial colonization on site or hub Internal jugular or femoral insertion site Neutropenia TP Substandard care of line CVAD Flushing: 10ml syringe or larger Flush before and after use After IV push medication, flush at same rate for first 2 - 5 ml of med After IV PGB, flush does NOT have to be done at same rate since med is more diluted After TPN or blood products: flush with 20ml Maintenance Flushing: NS for non-groshong and groshong Frequency dependent on hospital policy ○ Typically every 8 hr or every shift  Some hospitals may require heparin solution for final flush Blood Sampling through CVAD: Aspiration of blood brings fibrin and platelets into lumen, increasing RF thrombosis MD Ordered required for okay if a 1 lumen CVAD If multiple lumen CVAD, use proximal lumen if available Stop IV fluids for at least 30 seconds prior to collection to prevent contamination Make sure lab is present for collection Flush with 20ml Techniques for Obtaining Blood from CVAD: 1. Push-pull method: 10 ml syringe, draw 4-6 ml blood and reinfused back into CVAD, repeat cycle 4 times, then draw required blood for lab test a. Flush w/ 10 ml NS, change connector and flush w/ another 10 ml NS. Then lock and apply cyrus cap 2. Discard method: 10 ml syringe, draw 6-10 ml blood and discard. Connect a new syringe and draw the required volume of blood for the test. a. Flush w/ 10 ml NS, change connector and flush w/ another 10 ml NS. Then lock and apply cyrus cap Nursing: Things to know in preparation: ○ Type of CVAD, number of lumens ○ Anatomical location of tip ○ Flushing routines for this type of CVAD ○ Date of last dressing change ○ Date of next IV tubing change Initial Assessment: ○ Dressing intact? ○ CVAD junction luer locks secure? ○ All injection ports covered with curos cap ○ Lumens extending from CVAD secured ○ inspect/palpate site ○ Unilateral edema of hand, face, neck, chest? (indicative of thrombosis) ○ Pt reporting bubbling/whooshing during infusion? ○ Signs of infection? Tubing: ○ Continuous infusion: 96 hr ○ Intermittent infusion: 24 hr Potential comps of removing a line: 1. Air embolism: SOB, chest pain, decreased LOC, increased HR, decreased SPO2 2. Bleeding 3. DVT: redness, swooshing sound, pain, edema