Access Devices Flashcards
Gastric feeding
Generally reserved for patients with normal gastric emptying and low risk of gastric aspiration
Small bowel feeding
Preferred in the presence of gastric outlet obstruction, gastroparesis, severely increased risk of aspiration, and pancreatitis
Gastrojejunal tube systems
Allow for simultaneous gastric decompression, and small bowel feedings. May be indicated for gastric outlet obstruction, severe GERD, gastroparesis, and early (postoperative) feeding
The use of small bowel feeding to reduce the risk of aspiration PNA is controversial, although recent data and meta-analysis suggest this feeding approach may be of benefit.
(T/F) Most NG or nasoenteric tubes are constructed of polyurethane.
TRUE
It allows for a relatively larger inner tube diameter for a given outer diameter size
(T/F) Most PEG tubes are constructed out of silicone.
TRUE
Silicone has inherent material longevity and comfort.
(T/F) You can use Foley catheters or red rubber catheters for enteral feeding.
FALSE
That is no longer possible due to the 2017 mandate to have ENfit connectors
(T/F) All feeding tubes sizes are reported by the tube’s internal diameter measurement.
FALSE
Measured by the EXTERNAL diameter measurement.
Flow through the tubes and susceptibility to clogging depends on the tube’s inner diameter. The inner diameter may vary depending on the specific material used to construct the tube.
What is generally true about the diameter size with polyurethane and silicone tubes?
Polyurethane tubes with the same outer diameter as a silicone tube will have a larger internal diameter that may be less likely to clog.
What are stylets or guidewires?
They are provided with most nasoenteric feeding tubes to provide tube structure and/or guidance while passing these relatively floppy tubes.
Designed to be shorter than the length of the tube and to have a flexible distal tip to avoid perforation of the GI wall.
When are water-activated lubricants used?
Used to coat the tube’s internal lumen to allow easier removal of the stylets or guidewires after the feeding tube is in place.
What is the difference between a 1-port and a Y-port?
1 port for feeding
Y-port has one port for feeding and the other for medication and/or irrigation.
(T/F) Dual ports allow for concomitant feeding and medication administration and/or irrigation.
TRUE
However, to prevent clogging, medications should be administered through the tube only after the TFs are HELD and the feeding tube is flushed with water.
What is the Global Enteral Device Supplier Association?
A non-profit trade association formed to introduce the new international standards for enteral feeding connectors that are designed to increase patient safety and optimal delivery of EN by reducing the risk of tubing misconnections. ENfit connectors.
(T/F) Weighted tube tips facilitate the transpyloric passage when placing a feeding tube.
FALSE
Research does not demonstrate a clear advantage with the use of either weighted or unweighted tips.
When and why are solid internal bolsters used?
More common in initial percutaneous enterostomy tube placement
Have greater longevity
When and why are balloon-type internal bolsters used?
Inserted more commonly with radiologic and surgical tube placement; used as replacement devices in office settings because of their ease in placement.
How much volume will a balloon-type internal bolster be filled with, if placed in the small bowel? And why?
Not typically more than 3-4 mL, so it will not obstruct the lumen.
How long do balloon-type internal bolsters last?
4 - 6 months.
What bolster type (balloon-type or solid) is preferred for a direct jejunal tube placement? And why?
Non-balloon-type is preferred; to avoid occluding the narrower jejunal lumen.
What is a solid internal bolster constrained with a dissolvable capsule? When is it used? What is the benefit?
It is placed in the same manner as a balloon-type; used for laparoscopic initial gastric or direct jejunal tube placement, and as replacements.
The benefit is that it combines the longevity of a solid internal bolster with the ease of placement of a balloon-type bolster
(T/F) Internal balloon-type bolsters have 3 ports.
TRUE.
1 for feeding; medications/irrigation; balloon inflation/deflation
What is the gold standard for confirmation of feeding tube placement?
Plain abdominal or chest radiography
(T/F) Feeding tubes should not be used for feeding until confirmation of proper position.
TRUE
What are added to bedside techniques and may increase success rates of feeding tube placement?
Prokinetics (erythromycin or metoclopramide).
IV Erythromycin (in doses of 200-500 mg) had the highest success rate.
What are two devices that have been developed to assist with nasoenteric tube placements?
Bedside magnet, and electromagnetic imaging system (success rates have been documented as greater than 90%).
What is the reported bedside success rate for nasoenteric tubes? What is the success rate for endoscopic and fluoroscopic placement?
56 - 92% for bedside
Greater than 90% for endo- and fluoro-
(T/F) The American Society of Gastrointestinal Endoscopy guidelines consider placement of a percutaneous feeding tube to be a high-bleeding-risk procedure.
TRUE
Routine pre-procedural testing of coagulation parameters and platelets is no longer recommended for patients undergoing enterostomy tube placement. But these should be considered if there is a concern.
How long should:
- Thienopyridines
- Warfarin
- Aspirin
be held for, in relation to a PEG placement? If these cannot be held, what is recommended?
- Thienopyridines: should be held for 5-7 days BEFORE
- If holding is not possible: Sometimes EPINEPHRINE will be added to the lidocaine for local anesthesia, and clinicians will make sure the bolsters are firm (not tight) for 3-4 before loosening them.- Warfarin: should be held 5 days BEFORE; High-risk patients should be bridged with short-acting heparin and the new direct-acting oral anticoagulants should be held for at least 48 hours BEFORE the procedure, and restarted up to 48 hours AFTERWARDS.
- Aspirin regimens should be continued in patients with high thromboembolic risk.
What medication is administered when enterostomy tubes are placed?
Prophylactic antibiotics; are shown to decrease peristomal infection rates when using endoscopic methods for initial placement
Explain the Ponsky pull technique for PEG placement.
Most common; Endoscopy is fed through the mouth into the stomach. The placement for the feeding tube is determined through simultaneous endoscopic transillumination of the abdominal wall. A small incision is made at that site and a needle is inserted into the stomach. A guidewire is inserted within the needle and caught on the endoscopy snare. The guidewire is fed up to exit the mouth. The feeding tube is attached to the guidewire, then pulled from the placement site down into the mouth, esophagus, into the stomach and through the abdominal wall, until it is in place. The internal bolster holds it in place, and an external bolster is placed on the outside.
What are the advantages of a PEG placement?
- Performance at bedside
- Lack of radiation
- Ability to perform diagnostic and therapeutic endoscopic procedures simultaneously.
What are the contraindications for endoscopic PEG placement?
Specific:
- Obstruction of GI tract proximal to the stomach
- Inability to transilluminate the abdominal wall for ID of safe abdominal access
Relative:
- Ascites
- Coagulopathy
- Gastric varices
- Active head and neck cancers
- Morbid obesity
- Neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall
What are the advantages of fluoroscopic gastrostomy placement?
- Lack of need for conscious sedation in some patients
- Ability to perform in patients with severe stenosis/trauma of the upper GI tract
- Potentially decreased risk of tumor seeding from upper aerodigestive tract cancers
When is surgical placement of feeding tubes used? (3)
AKA Laparoscopic or open (laparotomy) method: is performed in the operating room under general anesthesia.
- When patients are undergoing another abdominal operation
- When endoscopic and radiologic attempts fail
- And/or in the presence of an aerodigestive tract obstruction or facial trauma
What is the Stamm technique?
the most commonly used surgical placement of an open G-tube
In what situations is a percutaneous endoscopic gastrojejunostomy (PEJ) indicated?
- Impaired gastric motility
- Pancreatitis
- s/p pancreatic surgery
- Anytime enteral feeding into the small bowel with simultaneous stomach decompression is required.
Explain how a PEG-J is placed.
Most commonly, a guidewire is placed through the existing gastrostomy, grasped endoscopically and carried into the jejunum. The endoscope is then withdrawn, leaving the guidewire in place. The jejunal extension tube is threaded over the guidewire into the small bowel.
Some methods include use of reclosable clips.
When is fluoroscopic feeding tube placement appropriate?
When endoscopy cannot be performed!
How is a direct jejunostomy tube placed?
Various fluoroscopic ways
How is direct percutaneous jejunostomy placed?
Either endoscopic or fluoroscopic guidance; more difficult than placing a percutaneous gastrostomy.
When can enterostomy tubes be safely removed or replaced?
After the stoma tract has matured. Maturation occurs 1-2 weeks after initial placement, but clinicians prefer to wait 4-6 weeks prior to removal to ensure it is mature.
What could happen if an enterostomy is removed before the stoma tract is mature?
Stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum
What is the type of liquid and how much should be used for balloon-type bolsters for gastric tubes? Small bowel tubes?
Sterile water, 5-20 mL for gastric tubes & 3-4 mL for small bowel tubes.
How do you properly clean the stoma site?
Mild soap and water, thoroughly rinse and dry area
(T/F) The use of antibiotic ointments and hydrogen peroxide at the tube site is recommended for cleanliness.
FALSE. Dressings can be applied if there is drainage from the stoma site, but avoid excessive tension which can promote infection and buried bumper syndrome.
(T/F) Whether medications is in a pill or liquid form, each medication should be given separately with a water flush, before and after each medication administration.
TRUE.
Liquid form medications may contain higher amounts of sorbitol/sugar, have a higher osmolarity, and/or a higher viscosity, and may be more expensive than a tablet form.
Giving a crushed and diluted medication could be more preferable; however; crushed pills can be more likely to clog a small-bore tube than medication in a liquid form.
What is the overall success rate for procedure-rated complications for placing NG tubes?
~10%; epistaxis, aspiration, and circulatory or respiratory compromise
~2-4%; misplacement of NG tube into bronchopulmonary tree
What is the gold standard for ensuring correct feeding tube placement?
RADIOGRAPHY
What are postprocedural complications for NG tubes?
- Inadvertent tube dislodgement (~25-41% of cases)
- Tube malfunction (~11-20% of the time)
- Tube occlusion (~20-45% of the time)
- Intestinal ischemia
What method significantly reduces NG tube dislodgement?
Nasal bridle; decreases from 36% to 10%
What results in buried bumper syndrome? What are the risk factors?
From growth of the gastric mucosa over the internal bumper.
Risk factors: excessive tension between the internal and external bumpers, poor wound healing, and significant weight gain
What are some methods that can be used for patients prone to pulling tubes?
- Use of abdominal binder
- Mittens over the patient’s hands
- Decreasing the external tube length to 6 to 8 cm
- Switching to a low-profile device
**Where does ASPEN recommend feeding first?
**Stomach as a first choice.
Note, that recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration PNA.
Factors that should be considered when determining the type of enteral access device?
Underlying disease
Gastric and small bowel function
Short- and long-term goals
Anticipated length of therapy
Risk factors related to the method of placement
Ethical considerations
Is a patient with head and neck cancer a candidate to receive an enteral feeding device? If so, what type of enteral feeding tube should be used?
Scenario: 72 y/o M w/ metastatic squamous cell carcinoma of tongue. Scheduled for 6 week course of chemo and radiation. Wt 80 kg, lost 11 kg in 3 months (14% wt loss). Labs WNL.
Could benefit from an enteral feeding tube to address both his existing malnutrition as well as likely further decreases in oral intake related to mucositis, nausea, and vomiting from chemoradiation. Expected duration of therapy is at least 6 weeks. Percutaneous gastrostomy tube (G-tube) is appropriate
What is the “introducer” method of G-tube placement?
Used by interventional radiologists, surgeons, or endoscopists to minimize the risk of tumor implantation during G-tube placement in a head/neck cancer patient. The stomach is insufflated and anchored to the anterior abdominal wall with T-fasteners, and the G-tube is introduced percutaneously. In this manner, the tube is not pulled through the region with active cancer and risk for tumor seeding is decreased
What type of long-term tube (stomach or small bowel) should patients receive if they have the preexisting condition of GERD? Does the answer change if the patient is in the ICU?
Whenever possible, patients should be fed into the stomach as it is the most physiologically normal for the body, ensuring appropriate mixing of nutrients with gastric acid. Feeding into the stomach also allows for schedule flexibility, is the safest with regard to formula contamination secondary to no formula hang time, allows for blenderized diets, and is the most cost-effective. IF the patient does not tolerate gastric feeding or has an aspiration event, the feeding can be diverted to the small intestine
All feeding tube sizes are reported by the tube’s internal or external diameter measurement?
External
The flow through the enteral tube and susceptibility to clogging depend on a tube’s inner or outer diameter?
Inner
Polyurethane tubes with the same outer diameter as a silicone tube will have a smaller or larger internal diameter?
Larger
Differences in characteristics of polyurethane vs silicone tubing
Silicone tubes are more comfortable and less stiff than polyurethane
Wall width is thinner in polyurethane and they are more resistance to fungal degradation
Nasoenteric feeding tube port comparisons and options?
Have either 1 port for feeding or 2 in a “Y” configuration: one for feeding and the other for medication and/or irrigation
Factors that determine which type of feeding tube tip to use?
There is no specific data to favor one design over another (weighted vs unweighted; side vs end feeding holes; number of distal feeding delivery holes)
The choice is determined by the preference of the individual clinician, institutional availability, and mode of placement
What are the two options for an internal retention bolster for percutaneous tubes?
Solid material (silicone or polyurethane) or silicone balloons
What type of internal retention bolster is more commonly used with initial percutaneous enterostomy tube placement and why?
Solid internal bolster. They have greater longevity
Why would a silicone balloon internal bolster be used?
Ease in placement
Define some characteristics of the use of a silicone balloon internal bolster?
Ease of placement. Inserted more frequently with radiologic and surgical tube placement, and used as replacement devices in the office setting. If placed in the small bowel, the balloon is typically filled with a volume of 3-4 ml so as not to obstruct the lumen. Typically only have a lifespan of 4-6 months. Use of a nonballoon tube is preferred for direct jejunal tube placement to avoid occluding the narrower jejunal lumen.
Describe the characteristics of an enteral feeding tube with a solid internal bolster constrained in a dissolvable capsule that can be placed in the same manner as a balloon tube
May be used for laparoscopic initial gastric or direct jejunal tube placement, as well as for replacement tubes. It combines the longevity of a solid internal bolster with the ease of placement of a balloon-type internal bolster tube
Why would a percutaneous enterostomy feeding tube have multiple ports?
Separate ports are included for feeding and medication and/or irrigation. Balloon-type internal bolsters also have a third port for balloon inflation or deflation
Difference in placement of a gastrojejunal vs jejunal feeding tube?
Percutaneous gastrojejunal feeding tubes are inserted into the stomach with a smaller-bore extension tube that passes through the pylorus into the jejunum. Some are specifically designed with separate gastric and jejunal lumens and have ports that allow for both jejunal feeding and gastric decompression. Direct percutaneous jejunostomy tubes are placed directly into the jejunum without passage through the stomach
What are low-profile tubes?
Skin-level devices that are used as initial placement or, more commonly, for replacement devices for gastrostomies, gastrojejunostomies, and jejunostomies. Excellent option for patients who are concerned about the cosmetic appearance of a feeding tube. Can also be more comfortable for patients who are active, sleep in the prone position, or need only intermittent therapy. Patient will need adequate manual dexterity or caregiver assistance to attach a feeding connector to a skin-level device
When is nasogastric or nasoenteric tube placement contraindicated?
When patient has an obstructing head, neck, and esophageal pathology or injury that prevents safe insertion
Which prokinetic had the highest success rate when passing a feeding tube post-pyloric?
IV erythromycin
What are the available methods to place long-term enterostomy tubes?
Endoscopic, fluoroscopic, or surgical
When should preprocedural testing of coagulation parameters and platelets be done before long-term feeding tube placement?
If there is concern for abnormal coagulation due to anticoagulant medication< medical history of excessive bleeding, or recent antibiotic use
Is placement of a percutaneous feeding tube considered a high- or low-bleeding risk procedure?
High-bleeding risk
Name specific and relative contraindications for endoscopic gastrostomy tube placement?
Specific: obstruction of the GI tract proximal to the stomach and the inability to transilluminate the abdominal wall for identification of a safe abdominal access site
Relative: ascites, coagulopathy, gastric varices, active head and neck cancers, morbid obesity, and neoplastic, infiltrative, or inflammatory disease of the gastric or abdominal wall
Describe the Ponsky (pull) method of PEG tube insertion?
Air is insufflated into the stomach via endoscope. The optimal site for PEG tube placement is determined through simultaneous endoscopic transillumination of the abdominal wall and endoscopically visualized finger indentation at the site. A small incision is made at this site and a needle/trocar is inserted through the abdominal wall and into the stomach. A guidewire is passed through the endoscope; then, the guidewire, snare, and endoscope are withdrawn through the mouth. A G-tube is affixed to the guidewire and pulled through the esophagus into the stomach and out the abdominal wall. The G-tube is held in place by a solid, mushroom-type internal retention device and an external bumper
Name advantages of PEG placement?
Performance at bedside, lack of radiation, and ability to perform diagnostic and therapeutic endoscopic procedures simultaneously
Describe the first of 2 fluoroscopic methods of percutaneous G-tube placement (the more common method)
A NG tube is placed to insufflate the stomach, a safe window is identified under fluoroscopy, and 1 to 4 T-fasteners are used to perform a gastropexy to secure the stomach wall to the abdominal wall. A needle is used to obtain gastric access, the guidewire is advanced through the needle, and the tract is dilated sequentially until there is a large enough hole for the tube to go through. Lastly, the G-tube is placed through the tract using a peel-away sheath.
Describe the second of 2 fluoroscopic methods of percutaneous G-tube placement (the less common method)
Uses a slightly curved 18-gauge needle or vascular sheath; it is advanced into the stomach and pointed toward the gastroesophageal junction after gastric insufflation. The guidewire is then advanced with or without the help of an angiographic catheter into the esophagus and oropharynx and out of the mouth. A G-tube is then threaded over the wire, advanced until it emerges from the abdominal wall, and then pulled into the desired position.
What are advantages of fluoroscopic gastrostomy placement?
Lack of need for conscious sedation in some patients, ability to perform in patients with severe stenosis/trauma of the upper GI tract, and potentially decreased risk of tumor seeding from upper aerodigestive tract cancers
When would surgical placement of a feeding tube take place?
Used when patients are undergoing another abdominal operation, when endoscopic and radiologic attempts fail, and/or in the presence of an aerodigestive tract obstruction or facial trauma
When would direct laparoscopic gastric tube placement occur?
When endoscopic or radiologic placement fails or is not available
Describe the laparoscopic technique of placing a feeding tube?
Accesses the peritoneal cavity by way of small ports that enter through the abdominal wall. A pneumoperitoneum is created through a port inserted just below the umbilicus through which a camera is passed. The stomach is accessed an manipulated through a second port entering the LLQ and a third port entering through the RUQ. T-fasteners or laparoscopic sutures are placed to affix the stomach to the abdominal wall. The procedure then proceeds in a manner similar to fluoroscopic gastrostomy, with a hollow needle advanced percutaneously into the stomach lumen followed by wire, dilators, peel-away sheath, and finally the G-tube
Describe the Stamm technique of surgical placement of an open G-tube?
Requires a small laparotomy in the upper midline of the abdomen. The G-tube is brought into the stomach through a small stab wound in the upper abdominal wall. A small incision is made into the stomach through which the feeding tube enters and around which purse-string sutures are placed to secure the stomach around the G-tube. The stomach is then sutured to the anterior abdominal wall. This tube may be held in place with an inflated balloon or sutured to the abdominal wall to prevent tube migration
What is a risk with gastrojejunal tubes?
The jejunal tube piece might migrate back into the stomach
Describe the process of fluoroscopic gastrojejunal tube placement?
Initial steps similar to fluoroscopic gastrostomy placement. To facilitate placement of the gastrojejunostomy, puncture of the stomach is performed in the direction of the pylorus. A guidewire is advanced through the stomach to the ligament of Treitz, and the jejunal extension tube is advanced over the wire into the jejunum. Fluoroscopic technique can be used when patient cannot undergo endoscopy
Why are endoscopic jejunostomy tubes more stable than fluoroscopic tubes?
The endoscopic tubes have solid, mushroom-type internal bolsters and larger tube diameters (18-20 Fr vs 10-14 Fr)
When does maturation of the enterostomy stoma tract usually occur?
1-2 weeks after initial placement, but many clinicians prefer to wait 4-6 weeks prior to removal to ensure the stoma tract is mature
Size and length of nasogastric tubes?
8-16 Fr, 38-91 cm
Size and length of nasoenteric tubes?
8-12 Fr, 91-240 cm
Size of gastrostomy tubes?
12-30 Fr
Size of gastrojejunal tubes?
6-14 Fr
Size and length of jejunal extension through existing gastrostomy?
8-12 Fr, 15-95 cm
Size of dual lumen (gastric and jejunal) tubes?
16-30 Fr
Size and length of single lumen (jejunal only) tubes?
12-24 Fr, 15-58 cm
Size and length of low-profile gastrostomy (replacement) tubes?
12-24 Fr, 0.8-6.5 cm
Size and length of low-profile gastrojejunostomy tubes?
14-22 Fr, 15-45 cm
What are potential complications of removing G-tubes before stoma tract maturation?
May result in the stomach or small bowel falling away from the abdominal wall, allowing bowel contents to leak into the peritoneum
Describe the traction method of removing a percutaneous feeding tube with a solid internal bolster?
Patient is placed in the supine position with knees bent to relax the abdominal muscles. The exposed gastric tubing is firmly grasped and pulled forcefully
Usual causes of clogged feeding tubes?
Suboptimal flushing
Not flushing prior to and after each medication
Accumulation of pill fragments
Frequent residual checks
Administration of high-protein or high-fiber formulas
Prophylactic methods to help prevent clogging?
Compliance with intermittent flushing protocols
Using water as the flush fluid of choice
Prophylactic use of pancreatic enzymes to prevent tube occlusion
Nasal tube complications during the insertion period?
Epistaxis, aspiration, circulatory or respiratory compromise - occurrence of 10%
Initial misplacement of nasoenteric tube into the bronchopulmonary tree - occurrence of 2-4%
Postprocedural complications of nasal feeding tubes?
Inadvertent tube dislodgement (25-41% of cases)
Tube malfunction (breaking, cracking, or kinking - occurs 11-20% of the time)
Sinusitis (12% occurrence)
Tube occlusion (20-45% occurrence)
Tube feeding aspiration
Intestinal ischemia
The incidence of accidental tube dislodgement decreases from 36% to 10% when what is used?
When magnet-based system was used to place a nasal bridle
Risk factors for nasal tube occlusion?
Increasing tube length
Decreasing tube caliber
Inadequate water flushing
Frequent medication delivery
Use of the tube to measure residual volumes
Name the major post-procedure complications of enterostomy tube placement and their reported frequency
Aspiration (0.3-1%)
Hemorrhage (0-2.5%)
Peritonitis/necrotizing fasciitis (0.5-1.3%)
Death (0-2.1%)
Name the minor post-procedure complications of enterostomy tube placement and their reported frequency
Peristomal infection (5.4-30%)
Peristomal leakage (1-2%)
Buried bumper syndrome (0.3-2.4%)
Inadvertent removal (1.6-4.4%)
Fistulous tracts (0.3-6.7%)
Procedural complications of percutaneous enterostomy tubes?
Intraprocedural aspiration
Hemorrhage
Perforation of the GI lumen
Prolonged ileus
Risk factors for leakage around the gastrostomy site?
Infection
Excessive cleaning with irritant solutions (hydrogen peroxide, povidone-iodine)
Excessive tension and side torsion on the external portion of the feeding tube
How do you address leakage around the gastrostomy site?
Prompt treatment of infection
Good ostomy skin care
Loosening of the outer bumper
Stabilizing the G-tube to prevent torsion on the tube
What should you do if a G-tube is accidentally removed and a standard tube is not promptly available?
A suitably sized Foley or red rubber catheter can be used to keep the tract open until a standard replacement tube can be placed
Ways you can reduce the chance of a patient accidentally pulling their G-tube (if prone to pulling tubes)?
Use of an abdominal binder
Placing mittens on patient’s hands
Cutting down the external tube length to 6-8 cm
Switching to a low-profile device
Along with the same complications present for G-tubes, what are additional complications for GJ- and J-tubes?
GJ-tube: frequent (up to 70%) malfunction, migration, and/or occlusion of the smaller jejunal extension tube
J-tube: jejunal volvulus and/or small bowel perforation
True or false: jejunal feedings are confidently associated with lower aspiration risk
False, not definitive and needs more research. Expert opinion is to feed more distal with jejunal feeding to reduce risk of aspiration. Recent data and meta-analysis suggest that jejunal feeding may be associated with decreased risk of aspiration
Describe oral hygiene and skin care recommendations for feeding tubes?
All patients require appropriate oral hygiene regardless of tube type or insertion technique. Important for preventing aspiration pneumonia in ventilator-dependent patients or those with a depressed LOC.
Nasal tube: benefit from skin care to nasal area to address prolonged exposure to tape and adhesive products; repositioning nasal tube and avoiding pressure to nares is important to prevent pressure necrosis
Percutaneous: use mild soap and water to cleanse stoma site. Rinse and thoroughly dry area. Avoid routine use of antibiotic ointments of hydrogen peroxide. Dressing may be applied to stoma site if there is drainage, but should not be placed with excessive tension (can promote infection and buried bumper syndrome)
What is the complication in a patient with percutaneous gastrostomy tube (G-tube) who develops abdominal pain after tube exchange?
Scenario: Patient has a 24 Fr gastric balloon decompression tube that was initially placed several years ago and is regularly changed by patient at home. Patient uneventfully changed gastric tube the day before presenting to ED with severe abdominal pain. Awoke in the middle of the night with gastric leakage and intense pain around feeding tube. Unable to aspirate any gastric fluid from the feeding tube or move the tube within the tract. Skin very reddened and ulcerated from leakage of gastric fluid.
If patient develops abdominal pain after percutaneous feeding tube replacement, the concern is that the tube was potentially placed within the stoma tract instead of correctly into the gastric lumen or perforated into the peritoneal space. Most often occurs when there has been difficulty with tube replacement, but it can also occur when replacement is reported to go smoothly. When malpositioned tube is suspected, the tube position should be evaluated fluoroscopically or endoscopically. Treatment depends on how severe the problem is and if there has been contamination of enteral feeds into the peritoneal cavity. If significant peritoneal contamination has not occurred, the malpositioned tube can be removed and another tube placed using the same tract. If more significant disruption of the tract occurs, patient can be supported with nasoenteric feeding tube while the stoma tract closes and any infection is treated. If significant leakage has occurred and abdominal sepsis develops, patient is supported with IV fluids and antibiotics along with surgical consultation
Define diameter.
Can refer to the internal or external diameter and is measured in millimeters
Define french size.
A measure of the outer diameter (1 mm = 3 Fr)
Define gauge.
A unit of measure that is inversely proportional to the catheter’s outer diameter
What are the CDC guidelines for peripheral access?
Recommend close monitoring; with the peripheral IV line removed no more frequently than every 72 to 96 hours, unless clinically indicated.
What is purpose of cuffs?
Cuffs attached to CVCs are designed to serve as subcutaneous anchors and mechanical barriers.
What is the most commonly used line for the acute care setting, for short duration?
Nontunneled, noncuffed CVADs; they have a dwell time of 5 to 7 days.
Define CVAD
Central Venous Access Devices
Define PICC.
Peripherally Inserted Central Catheter A catheter inserted via a peripheral vein with the tip in the SVC (superior vena cava); classified as nontunneled
What are the 3 categories of CVADs?
- Nontunneled
- Tunneled
- Implanted
(TRUE/FALSE)
Stabilization devices are necessary to maintain PICC placement and avoid malposition.
TRUE
Describe tunneled central venous catheters, including their advantages.
Silicone elastomer catheter was inserted by subclavian venipuncture, with the distal tip placed in the midatrium; last for months to years
Advantages:
- Ease of self-care by the patient
- Placement on the chest wall so they are covered by clothing
- Decreased risk of dislodgement
- Ability to reapir the external lumen in the event of catheter breakage
Describe TIVADs
Totally Implanted Venous Access Devices (TIVADs)
Consist of silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysufone or titanium with a self-sealing silicon elastomer septum
Can be implanted into the subcutaneous pocket in the upper chest, upper arm, or forearm.
What are the patient factors to consider when choosing an appropriate catheter?
- Safe
- Meets the patient’s needs
- Cost-effective
- Type of medication/solution to be delivered
- Overall therapeutic regimen
- Anticipated duration of therapy
- Patient’s lifestyle
- Potential impact of the device on the patient’s body image
- Their activity level
How often should CVADs and mid-line catheters be assessed? For peripheral catheters?
Daily
At least Q 4 hours
What are the appropriate antiseptic agents for cleaning a catheter exit site?
- CHG (chlorheidine gluconate)
- 70% alcohol
- 10% povidone-iodine
What are the appropriate drying times for catheter sites?
- Alcohol/CHG: must dry at least 30 seconds
- Iopophors: at least 1.5 to 2 minutes
Agents must be fully dried before dressing is applied.
(TRUE/FALSE)
Routine use of antibiotic ointments at the catheter insertion site is recommended.
FALSE
Not recommended because they may change the bacterial flora and contribute to the emergence of resistant bacteria or fungi
Define hub.
The end of the VAD that connects to the medication tubing or caps.
Define CRBSIs.
Catheter-related Bloodstream Infection
Includes: Elevated WBC (greater than 10,500/mcL), fever, chills, N/V, hypotension, tachycardia
(TRUE/FALSE)
VADs should be assessed for blood return prior to each infusion and flushed with NS after each infusion to clear all infused medications or solutions.
TRUE
These steps help ensure catheter patency by reducing the risk of incompatible medications causing preciptations, and decreasing the risk of intraluminal occlusion by the reflux of blood into or remaining in the catheter.
Define a locking VAD.
The instillation of a limited amount of antimicrobial or antiseptic solution with sufficient volume to fill the internal priming volume of the catheter, following routine catheter flush.
Solutions include:
- Ethanol
- Taurolidine
- Citrate
- 26% sodium chloride
- EDTA
(TRUE/FALSE)
CDC guidelines recommend that the practice should be limited to patients with long-term catheters who have a history of multiple CRBSIs, and a systematic review of the clinical trials supported by this recommendation.
TRUE
Define CLABSI.
Central Line-Associated Bloodstream Infection; Clinical term used for diagnosis and tx of BSI
A labatory-confirmed BSI in which the central line or umbilical catheter was in place for more than 2 calendar days on the date of the event, with day of device placement being Day 1, AND the line was also in place on the date of event or the day before.
Describe the “Central Line Bundle.”
Proposed set of evidence-based practices,, which has been designed to reduce the incidence of infections associated with central lines.
- Hand Hygiene
- Maximal barrier precautions
- CHG skin antisepsis
- Optimal catheter site selection
- Daily review of line necessity, with the prompt removal of unnecessary lines
(TRUE/FALSE)
In reference to the “Central Line Bundle,” failure to complete any aspect of the bundle is regarded as noncompliance with the entire protocol.
TRUE
How is catheter patency defined?
With 2 criteria: the ability to infuse without resistance and the ability to aspirate blood without resistance. When either of these criteria is not met, the catheter is occluded.
Define venous thrombosis.
Refers to a thrombus in the vessel that may partially or totally occlude the vessel.
What is Alteplase?
A tissue plasminogen activator, approved thrombolytic agent for CVAD occlusions.
2 mg in a 2-mL volume is injected into the catheter and allowed to dwell for 30 minutes to 4 hours, then aspiration of the solution is attempted. Repeat if necessary.
(TRUE/FALSE)
In patients with catheter-associated mural or venous thrombosis, catheter removal is recommended as the first treatment.
FALSE, it is NOT recommended.
What are the leading causes of intraluminal occlusions?
- Drug-heparin interactions
- PN formulations
- Lipid residue
(TRUE/FALSE)
The use of a 0.9% NS flush between all IV medications, infusions, and heparin is the key to prevention.
TRUE
Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention sets ____ that create specialized vascular access teams
guidelines
what is the goal of an effective infection control program
eliminate CRBSI from all patient care areas
The major blood vessel that receives blood from the external jugular veins
Superior Vena Cava
what blood flow can the SVC can handle up to ____mL per min
2000mL
the preferred vessel or central access and infusion of PN solutions
SVC
maximum osmolarity peripheral veins
900mOsm/L
diameter of a catheter is the ____ or ____ diameter measured in mm
internal or external diameter
French size measures the _____ diameter of a catheter
outer
the gauge is a unit of measure that is ______ proportional to catheters of the outer diameter
inversely
____ lumen catheters allow for simultaneous infusion of multiple solutions or incompatible drugs’
multi-lumen
____ are attached to central venous catheters that act as subcutaneous anchors or mechanical barriers
cuffs
a ____ venous access device is a pressure sensitive, 3-2ay slit valve that prevents retrograde blood flow and eliminates the need for daily heparinized flushes
Groshong
moth IV catheters are made of _____
polyurethane
silicone IV catheters have an increased of _____ ____ formation
fibrin sleeve
catheter access is defined by the position of the
distal catheter tip
peripheral vein preservation should be considered when placing IV access. make sure solutions are these 3 things
non-irrtiant
non-vesicant
non-hyperosmolar
if a patient is fluid restricted, this type of access should not be used as they won’t be able to meet their nutrient needs
PPN
the most commonly used VAD are ____lines
peripheral
sings of thrombophlebitis
pain, erythema, tenderness
how often should peripheral IVs be changed
when clinically indicated
CDC guidelines suggest that close monitoring of _______ access and remove the IV line no more frequently than every ____ to ____ hours unless clinically indicated
peripheral, 72-96 hours
Midline catheters are 8-10 cm long and lower the rates of
phlebitis, lower infection
midline catheters are indicated for ___ to ___ weeks
2-6 weeks
midline catheters don’t need to be
frequently changed
non tunneled catheters are most often used in this setting
acute health care
non tunneled catheters are only indicated for ______ ___ use
short term
this is the method of placing non tunneled catheters by accessing the vein with a small needle, placing a guidewire and removing the needle
Seldinger approach
what is the dwell time of a non tunneled catheter
5-7 days
tunneled catheters are a ____ term catheter proven to be safe of therapy up to months/years
long term
advantages of a tunneled catheter
ease of self care of the patient, placed on the chest wall so it is covered by clothing, decreased risk of dislodgment
Totally Implanted Venous Access Devices are also called
subcutaneous Ports
This type of catheter is made up of a silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysuflane or titanium
port
a port catheter can be accessed up to _____ to ____ times
1,000-2,000 times
port catheter’s have the _____ infection rates
lowest
picking an access device for a patient should take into consideration
safety, meets the patient’s needs, depends on medication needed, duration of therapy, impact on body image, impact on patient’s lifestyle and activity level
the ideal goal of home PN therapy is
to restore the patient to their prior level of function
the ____ the number of lumens the _____the chance or infection
lower, lower
what are contraindications to placing central venous access devices (CVADs)
change in Tx plan with sudden clinical deterioration
new/unexplained fever
absolute neutropenia <1,000 WBC per mL
platelet counts <50,000 plates within 2 hrs of placing
what is the MOST important thing to prevent infection/complications with IV placement
use of maximal barrier protections
maximal barrier protections include
cap, mask, disposable gown, gloves, large drape
immediate complications of catheter placement include
pneumothorax, air embolism, arrhythmia bleeding, cardiac tamponade
signs of pneumothorax
dyspnea, cough, hypoxia, chest pain with tachycardia
onset of chest pain, dyspnea, tachycardia, nausea, hypotension or enlarged neck veins can indicate this IV insertion complication
arrhythmia
_____ should be the only ones to use ultrasound guidance when placing IV’s
well trained clinicians
what is mandatory to do before using a IV after insertion
confirm the tip placement BEFORE use
what is the desired tip placement in the SVC
the distal 1/3 of the SVC or cavoartiral junction
what is the gold standard way to check IV placement
Chest Xray
this type of method uses P waves to provide real time tip confirmation as the catheter approaches the right atrium
Electrocardiography Guided CVAD
CVAD’s should be monitored every ___ hours in acute care
4 hours
the goal of catheter care is
to maintain vascular access and reduce the risk of complication
what can be used to clean a CVAD
chlorhexidine, 70% alcohol, or iodine
what is the MOST effective CVAD cleaning agent
Chlorhexidine
is routine use of antibiotic ointment on catheter insertion site recommended
NOOOOOOO
this part of the catheter that is the end of the VAD that connects to the medication tubing or caps
hub
what ensures catheter patency
assess blood return
what is a chemical agent that is not readily available in the U.S. shown to help prevent CRBSI’s
Taurolidine
what is the most common non-infectious complication with VADs
catheter occlusion
elevated WBC count >10,500 mc/L, fever, chills, malaise, nausea, vomiting, hypotension, tachycardia, headache, erythema, purulent exudate at insertion site and fever may indicate a
Catheter Related Bloodstream Infection
CLABSI stands for
Central Line Associated Blood Stream Infection
erythema or induration within 2 cm of the catheter exit site in the absence of concomitant BSI without concomitant purulence is indicative of
exit site infection
tenderness, erythema or site induration > 2cm of catheter site along the subcutaneous tract of a tunneled catheter in the absence of concomitant BSI
tunnel infection
purulent fluid in the subcutaneous pocket of a totally implanted IV catheter that might or might not be associated with spontaneous rupture and drainage or necrosis of the overlaying skin in the absence of a BSI
pocket infection
bacteremia or fungemia in a patient with IV catheter with at least 1 positive blood culture obtained from a peripheral vein is called
a blood stream infection
fever, chills and hypotension could indcate
a BSI
contamination of the IV catheter can come from these places
endogenous skin flora at insertion site
contamination of the hub by hands/devices
hematogenous seeding form a distant infection
contamination of the infusate
the most common cause of intraluminal contamination of long term VAD’s come from
the hub of the IV catheter
when a biofilm develops on an IV what should be done
remove the CVAD and start systemic antibiotics
what is used to prevent the development of biofilm
antimicrobial catheter locks
what is the primary cause of contamination that causes blood stream infections
hand contamination
this was designed to reduce the incidence of infections associated with central lines by the institute of healthcare improvement which consists of 5 components including proper hand hygiene, maximal barrier precautions, CHG skin antiseptics, daily review of line necessity, optimal cath site selection and prompt removal of unnecessary lines
Central Line Bundle
when a CRBSI is suspected what should be provided and how long should it dwell
70% ethanol cath lock solution 2mL for 6 hours
when is appropriate to remove a CVC in the setting of infection
if it is a fungal infection or staff aureus
_____ is an antiseptic that provides bactericidal activity to a broad range of bacteria and is less likely to promote bacterial resistance
70% ethanol lock solution
an air embolism is a ____ condition and often fatal
rare
sudden chest pain, dyspnea, headache and confusion and sometimes death are symptoms of
air embolism
if a patient is suspected to have an air embolism of the VAD what should be done
clamp the catheter and place the patient immediately in Trendelenburg with left lateral decubitus position
occlu sion of catheter lumens should be maintained at all times when not in use to prevent
air embolism
a blood clot that breaks off from another thrombus in the body that travels to the lungs occluding pulmonary blood vessels is called
pulmonary embolism
if a patient is suspected to have a pulmonary embolism what should be done
diagnose with a CT scan or ventilation perfusion scan and then use anticoagulation therapy
what is the most common non infectious catheter related complication
catheter occlusion
the ability to infuse into an IV without resistance and ability to aspirate blood without resistance is called
catheter patency
if an IV does NOT have the ability to infuse without resistance and blood cannot be aspirated without resistance this indicates
an occlusion
when a vessel wall injury occurs with catheter it leads to this type of occlusion
thrombotic
A bundle of platelets and blood cells composed of fibrin developed after a vessel wall injury is known as a
venous thrombi
this coagulation factor becomes cross linked and interwoven with platelets/leukocytes is known as
fibrin
what catheter to vein ratio prevents a DVT
1:3
risk factors for developing a thrombosis
catheter tip position, catheter material, type of infusate, length of catheter duration, multiple insertion attempts, previous CVC insertion
other signs of catheter occlusion
neck vein distention, edema, tingling or pain, tight feeling in the throat
inadequate flushing or blood reflux in the IV resulting in sluggish catheter Fx/occlusion is caused by
intraluminal clotting
if there is evidence of intraluminal clotting what is the treatmet
flush 2x the volume with 5-10mL of normal saline
a covering formed over the distal tip of the catheter is known as the
fibrin sheath
how can you tell if there is intraluminal clotting
when you flush the IV with saline following blood aspiration is inadequate
a sheath formed over the distal tip of a catheter is called
a fibrin sheath
when you are unable to aspirated blood from a catheter but it is still working there may be a
fibrin sheath
what is the best way to treat a fibrin sheath
thombolytic agent (atepelase)
a thrombus within the vessel that may partially or totally occlude a vessel if called a
venous thrombosis
this type of thrombosis may initially present as a venous obstruction
mural thrombus
Ateplase should dwell for
30 mins to 4 hours
this is a tissue plasminogen activator/thrombolytic agent used to get rid of IV thrombi
Ateplase
is catheter removal the first line of action
NOOOOO
other non occlusive causes of poor IV blood flow
kinks, sutures, clamps
an intermittent mechanical obstruction related to postural changes caused by catheter compression between the clavicle and 1st rib is called
catheter pinch off syndrome
what is the first line of therapy when catheter pinchoff syndrome is detected
remove the IV line
per the CDC, assess a peripheral IV every ____ to ____ hours an only remove if ____
72-96 hours, only if there is an issues
in order to provide TPN, the catheter tip needs to end where
the distal 3rd end of the SVC or RAJ
never advance any external portion of a catheter that has been in contact with the ______ into the insertion site
the skin
Trans lumbar or transhepatic central lines emptying into the _____ vena cava
inferior
which central line placements provide the highest risk of infection
femoral/inguinal
how is pinch off syndrome identified
when a patient puts their arm down at their side, the tip of the cath is pinched off but when they lift up their arm, the sensation is releived
the development of purulence/pus within 2 cm of an IV line is called
exit site infection
the development of erythema, tenderness and purulence greater than 2 cm of an IV site is called
Tunnel infection
the development of erythema over the port, purulent drainage, cellulitis or necrosis is called
pocket infection
What should IV’s be properly flushed with
10mL NaCl 0.9%
What method of flushing a catheter prevents a thrombotic occlusion
push, pause method where you give 10 short 1mL pushes interrupted by a brief pause to remove solids
an IV line should be _______ before and after hooking up and taking off TPN
flushed
this type of thrombotic occlusion occurs inside the lumen of the IV where you are unable to infuse or aspirate such as a calcium precipitate
intraluminal thrombus
this type of thrombotic occlusion fully occludes the tip and lumen, looking like a sock over the tip of the IV line
fibrin sheath
this type of thrombotic occlusion develops a partial occlusion with a tail over the tip identified when you flush saline and try to draw blood but you cannot flush it through or aspirate blood (no draw back)
Fibrin Tail
this type of thrombotic occlusion occludes around the lumen causing obstruction identified by sweeping at the arm, hard infusation caused from vessel wall injury where fibrin binds to the catheter surface
mural thrombus
what is used to dissolve acidic precipitates with a pH <6
HCL (0.1) N
what is used to dissolve lipid precipitates in an IV
ehtanol
what is used to dissolve alkaline drug precipitates with a pH >7
Sodium Bicarb
CRBSI stands for
Catheter Related Blood Stream Infection
what is the most common cause of a hospital acquired inefection
CRBSI
Ethyl Alcohol Lock Therapy kills ____ and ____ and decreases the adherence of bacteria to prevent CRBSIs
bacteria and fungi
this type of locking solution decreases the adherence of bacteria to avoid CRBSis
ethyl alcohol lock
this type of locking solution is not used in the US but is a broad spectrum anti-septic that prevents the growth of bacteria and fungi and does not cause antibiotic resistance
Taurolidine
Taurolidine is a great locking solution because it will not cause
antibiotic resistance
the HUB of a catheter can be wiped with _____ before use
alcohol wipe
the best way to prevent infection is to use ________________ with anti septic technique prior to and during insertion of catheters
maximum barrier protection
the best anti septic for IV lines is
2% aqueous chlorhexidine
the lower the number of lumens the _____ the risk for infection
lesser
avoid ______ to prevent catheter infection as it can increase fungal colonization and cause antibiotic resistance and has not been shown to decrease the rates of CRBSI’s
antibiotic ointment
a ______ central line has either a single or double lumen, is small in diameter and used in the geriatric or pediatric population
Broviac
a _______catheter can provide up to 3 lumens
Hickman
a ____ catheter comes in lumens that are equal in size
leonard
when checking PICC Placement, an EKG is used to assess _____ waves when the tip reaches the CAJ
P waves
when the P wave is at ____amplitude, the PICC Is at the correct location
maximum amplitude
a _____ cuff is attached to a catheter to help secure the IV lime via fibrous tissue ingrowth and creates a barrier to decrease the risk of infection by limiting migration of bacteria
surecuff
a _____ cuff contains antimicrobials that infuse over time
vitacuff
this type of IV access is surgically placed into the subcutaneous pocket in the anterior chest or arm as a peripheral vascular access system (PAS) ends in the inferior vena cava and has double lumen ports where you can infuse 2 compatible solutions as the 2 lumens are separated
implanted port (PAS)
the benefits of a port
long term use, minimal alteration in body image, lower infectious rate, can be used anywhere from 1 ,000- 2,000 times and is either single or double lumen
this type of IV access is surgically placed into the chest wall ending in the SVC
Port a Cath
this type of IV access has a valve on the side that only needs to be flushed with normal saline Q 90 days to maintain. It is usually used in patients who get intermittent chemo
Groshong Port
If a Groshong port is being used currently does it need to be flushed? how often
yes every week
what is the major cause of morbidity in home PN patients
septicemia
a very common complication of home PN nutrition is
catheter related infection
what is the most common cause of re hospitalization for HPN
Catheter Related Blood Stream Infections
Which venous access devices (VADs) are used for home PN include these 2 lines (when PN needed for >4 weeks)
Implantable Port/Tunneled Catheters
Hickman or Broviac
a patient undergoing radiation and chemo for cancer in the region of the mediastinum is getting TPN and reports wt loss, and pain/swelling in her neck/right arm. The likely cause of this is
a catheter related complication
large ____ in PPN must be provided to meet energy needs/protein compared to TPN and therefor not desirable when ___ restricted
fluid, fluid
when considering PPN suspected use should be for > ___ days
5
to avoid phlebitis, PPN lines are usually rotated every ___ hours
48-72 hours
contraindications to PPN are
significant malnutrition, severe metabolic stress, marked electrolyte needs, high doses of potassium, fluid restriction, needed for nutrition for >2 weeks and renal/liver compromise
the CDC recommends chlorhexidine/silver sulfadiazine or rifampin imprgenanted CVS if catheter is to remain in place > ___ days
5
enterococci can come from endogenous flora or ______
hands of health care workers
can candida (yeast) cause sepsis
yes
the gold standard for the treatment of a diagnosis of CRBSI is catheter removal, however in patients that require _______, catheter salvage is more desired than removal
long term IV therapy
Central Venous Catheter blood cultures that become positive over ____ hours sooner than peripheral cultures are considered predictive for CRBSI
2 hours
how can catheter salvage be obtained during suspicion of CRBSI
70% ethanol lock solution and systemic abx therapy
_______ing catheters are both considered a treatment and prevention for recurrent CRBSi’s
locking
when the tip of a catheter migrates into the heart chambers ____ can result in cardiac tamponade
pericardium puncture
____ injury can occur up to months after central line insertion where the patient has paralysis of the diaphragm leading to respiratory distress, decreased air flow to the lungs and decreased respiratory rate
phrenic nerve injury
symptoms of adverse reaction to lipide injectable emulsions
allergic egg reaction, cyanosis, flushing, sweating, nausea, vomiting, headache
azotemia in PN can result from
excessive protein/amino acid administration
Name 2 large central veins?
Inferior vena cava (IVC)
Superior vena cava (SVC)
Which is the main vessel for venous return from the upper trunk emptying into the right atrium?
Superior vena cava (SVC)
What is the preferred vessel for PN solutions via central access and its estimated blood flow per minute?
SVC
2000 ml/min
What does diameter refer to with catheter measurements?
Can refer to the internal or external diameter and is measured in millimeters. Depending on the catheter material, the internal diameter may vary between catheters with the same external diameter
What is French size?
A measure of the outer diameter (1 mm = 3 Fr.)
What is gauge measurement of catheters?
A unit of measure that is inversely proportional to the catheter’s outer diameter
What is a benefit of a multilumen CVC?
Provides for simultaneous infusion of multiple solutions or incompatible drugs
What is a CVC cuff?
Designed to serve as a subcutaneous anchor and mechanical barrier
What is a Dacron cuff?
Most often attached to tunneled catheters. Positioned in the subcutaneous tissue and serve to anchor the catheter by facilitating fibrous ingrowth
What is a collagen cuff?
Impregnated with silver ions, the gradual release of the silver ions exerts short-term antimicrobial activity
What is a Groshong catheter?
A venous access device with a pressure sensitive 3-way slit valve on the tunneled catheter which eliminates the need for daily heparinized flushes and catheter clamping before disconnecting at the catheter hub
What substance are catheters most often made of?
Polyurethane or silicone
What is a negative effect of using PVC catheters?
Have been associated with an increase in thrombus formation and phlebitis compared with other polymeric catheters
Describe some characteristics of polyurethane catheters?
Smooth surface which demonstrates resistance to hydrolytic enzymes. Greater tensile strength than silicone and lower degrees of microbial colonization
Describe characteristics of silicone catheters?
Excellent elasticity and softness, cause less damage to the vessel intima. Low inflammatory-provoking potential in the tissues, surface is less attractive for adherence of microbial populations when compared with other biomaterials. Tends to be chemically inert to blood with reduced plasma adherence
What is a common complication of silicone catheters?
Fibrin sleeve formation
Where are peripheral catheters inserted and where do they terminate?
Enter and terminate in peripheral veins in the hand and lower arm
Where is the tip located in central catheters?
Distal CVC, IVC, or right atrium
List advantages of peripheral catheters
Least expensive
Least risk for catheter-related infections
Does not require a special placement room
Clinicians easily trained in placement
What type of PN is not appropriate for peripheral use?
PN that has a final concentration >10% dextrose or other additives that result in an osmolarity >900 mOsm/L
What is the leading complication associated with peripheral access?
Peripheral venous thrombophlebitis
What are the hallmark signs of infusion phlebitis?
Pain, erythema, tenderness, palpable cord
Where does the catheter tip reside in midline catheters?
Basilic or cephalic vein, with the tip at or before the axilla, distal to the shoulder
What is an advantage of a midline catheter?
Lower phlebitis rates than standard, short peripheral catheters and lower rates of infection than CVADs
What type of IV therapy is a midline peripheral catheter appropriate for?
Peripheral compatible solutions where treatment is considered for 2-6 weeks
What are the most common sites of venipuncture for central access?
Cephalic, basilic, subclavian, jugular, and femoral veins
Which vein is preferred for SVC access for patients with CKD who might require dialysis?
Right internal jugular vein
Which catheter is ideal for all situations?
None, catheter choice is guided by the advantages and disadvantages with various optoins
A venous site where the catheter-to-vein ratio is equal to or less than what % should be selected to minimize the risk of venous thrombosis when placing a PICC?
45%
Where can PICC line placement occur?
At patient’s home, at the bedside, or IR
List some advantages of a PICC line?
Safer insertion in the arm
Cost-effectiveness
Convenience of placement by vascular access teams
What complications may PICC lines lead to?
Luminal occlusions
Malpositioning and dislodgement
Infection at PICC insertion site
Superficial thrombophlebitis at insertion site
True or false: PICCs are not appropriate for infusion of irritants and vesicants such as PN and chemo for any length of duration
False. They are appropriate
What is the theory behind catheter tunneling decreasing the risk of catheter infection?
It separates the exit and venipuncture sites
What is the length of time that tunneled catheters have been demonstrated to be safe and effective for?
Long-term therapies ranging from months to years
Name some advantages to tunneled CVCs
Ease of self care by the patient
Placement on the chest wall so they are covered by clothing
Decreased risk of dislodgement
Ability to repair the external lumen in the event of catheter breakage
What sites can be used when repeated catheterizations to common vein sites affect the likelihood of the vein’s preservation?
Translumbar, transhepatic, and transcollateral
Describe the characteristics of TIVADs
A silicone or polyurethane catheter attached to a portal reservoir made of stainless steel, polysulfone, or titanium with a self-sealing silicone elastomer septum
Where can TIVADs be implanted?
A subcutaneous pocket in the upper chest, upper arm, or forearm
How many times can TIVAD ports be accessed?
1000-2000 times
What is the goal of device selection for VAD?
To choose a device that is safe, meets the patient’s access needs, and is cost-effective
What factors play a role in the decision making process for choosing a VAD?
Type of medication or solution to be delivered
Overall therapeutic regimen
Anticipated duration of therapy
Patient’s lifestyle
Potential impact of the device on the patient’s body image and his/her activity level
What other factors need to be considered when choosing a VAD for patients in the home setting?
Cognitive ability and willingness to perform necessary tasks
What 3 factors were associated with the failure of placement of a CVC in the subclavian vein?
Prior surgery or radiation in the region
BMI >30 or <20
Previous catheterization
Why did the MAGIC expert panel rate insertion of devices (PICC, midline catheters) into the arm veins as inappropriate for patients with renal disease?
The need to preserve peripheral and central veins for possible hemodialysis or creation of arteriovenous fistulae and grafts
Where does the MAGIC expert panel recommend venous access for 5 days or fewer in renal disease patients?
Peripheral IV in the dorsum of the hand (avoiding the forearm veins) for peripheral-compatible infusates
What type of VAD does the MAGIC panel recommend when central access is needed for renal disease patients?
A tunneled, 4-Fr single-lumen or 5-Fr double-lumen inserted into the jugular vein and tunneled into the distal SVC
Why should clinicians choose a CVAD with the least number of lumens or ports appropriate for the patient?
Unnecessary lumens require more manipulation and access of the catheter, thereby increasing the risk for CVAD-related infection and complications
What are immediate complications of CVAD insertion?
Pneumothorax (most common)
Air embolism
Arterial puncture
Arrhythmia
Bleeding
How does the venous cutdown CVAD insertion approach virtually eliminate the risk of a pneumothorax?
Venous cutdown is performed using the cephalic, external jugular, or internal jugular vein. The vein is dissected and a venotomy allows the clinician to directly visualize the vessel while inserting the catheter
How has the use of ultrasound guidance improved placement of CVADs?
Increasing successful placement rates, reducing number of needle punctures, lowering the incidence of needle-stick complications
How often should CVADs and midline catheters be assessed?
Daily
How often should short peripheral catheters be assessed?
Every 4 hours
What should be used to cleanse the catheter exit site?
Antiseptic agent: chlorohexidine gluconate (CHG), 70% alcohol, or 10% povidone-iodine
CDC guidelines recommend skin should be prepped with what before catheter placement?
> 0.5% CHG preparation containing alcohol
Which antiseptic agent was found to be significantly more effective than the other 2 in decreasing both local infection and catheter-related sepsis: 2% aqueous chlorohexidine, 70% alcohol, or 10% povidone-iodine?
2% aqueous chlorohexidine
Why is the routine use of antibiotic ointments at the catheter insertion site not recommended?
They may change normal bacterial flora and contribute to the emergence of resistant bacteria or fungi
Describe the recommended process for hub disinfection by the Infusion Nurses Society
Perform a vigorous scrub for manual disinfection of the needless connector prior to each VAD access and allow to air dry. Length of contact time for scrubbing and drying depends on the design of the needless connector and the properties of the disinfecting agent
How often should VADs be assessed for blood return?
Prior to each infusion and flushed with normal saline after each infusion to clear all infused medication or solutions
How does assessing the VAD for blood return prior to each infusion and flushing with normal saline after each infusion help ensure catheter patency?
Clears of all infused medication or solutions
Reduces the risk of incompatible medications causing precipitation
Decreases the risk of intraluminal occlusion by the reflux of blood into or remaining in the catheter
What does it mean to lock a VAD?
The instillation of a limited amount of antimicrobial or antiseptic solution, with sufficient volume to fill the internal priming volume of the catheter, following routine catheter flush
Why is it recommended to aspirate all antimicrobial locking solutions from the CVAD at the end of the locking period?
Flushing the locking solution into the patient’s bloodstream could increase the development of antibiotic resistance
The CDC recommends the prophylactic use of antimicrobial locks to prevent CRBSI should be limited to what kind of patients?
Patients with long-term catheters who have a history of multiple CRBSIs
What is the purpose of effective catheter stabilization?
Helps prevent subtle movement of the catheter tip against the wall of the blood vessel, which can create irritation and promote thrombus formation
What is the most common noninfectious complication observed with the long-term use of VADs?
Catheter occlusion
What is the difference between CRBSI (catheter-related bloodstream infection) and CLABSI (central line-associated bloodstream infection)?
CRBSI is a clinical term used for diagnosis and treatment of a bloodstream infection. CLABSI is a surveillance term used by the CDC to determine a causal relationship between the catheter and bloodstream infection
What are the signs and symptoms of CRBSI?
Elevated WBC count, fever, chills, malaise, nausea, vomiting, hypotension, tachycardia, headache, backache
What are the 4 recognized sources from which CVC-related infections can originate?
Endogenous skin flora at the insertion site
Contamination of the catheter hub by hands or devices
Hematogenous seeding from a distant infection source
Contamination of infusate
What are the 2 primary portals for contamination of CVCs that have been identified?
The skin insertion site and the hub
What is the most frequent cause of intraluminal contamination in the long-term use of VADs?
Hub contamination
What is the predominant pathogen associated with infections from biomedical devices?
Gram-positive, coagulase-negative staphylococci
What increases the difficulty of successfully treating a catheter-related infection without removing the catheter?
The presence of a biofilm
What is the usual treatment for other infections such as sepsis and UTIs that can be caused by bacterial cells from the biofilm sloughing off and traveling in the bloodstream?
Removal of the CVAD and initiation of systemic antibiotic therapy
What is the primary means of nosocomial acquisition of bloodstream infections?
Hand contamination
Aside from hand contamination, what is another mean of nosocomial acquisition of bloodstream infections?
Microbial aerosols produced during periods of rhinorrhea
What factors are associated with the emergence of VRE (vancomycin-resistant enterococci)?
Previous antibiotic therapy involving third generation cephalosporins and vancomycin use
GI colonization with VRE
Severity of the underlying disease
Prolonged hospital stay
Use of indwelling VADs
What microbial pathogen occurs in approximately 60% of CVC infections?
Coagulase-negative staphylococci
Recurrent gram-negative infections of central lines have been observed in what kind of PN patients?
Patients with short bowel syndrome receiving PN
What are the 5 components of the Central Line Bundle?
Hand hygiene
Maximal barrier precautions
CHG skin antisepsis
Optimal catheter site selection
Daily review of line necessity and prompt removal of unnecessary lines
When should maximal barrier precautions be used?
During the insertion of CVCs, PICCs, or guidewire exchange
What should be done in the event of a CRBSI diagnosis in a patient that requires long-term IV therapy?
Catheter salvage using both a 70% ethanol lock as well as systemic antibiotic therapy
Removal of a catheter is recommended for what type of infections?
Fungal infections and S. aureus
Should the CVAD be used for blood sampling when PN is administered?
No, to reduce the risk of CRBSI
List noninfectious complications of CVADs
Air embolism
Pulmonary embolism
Catheter migration
Cardiac tamponade
Nerve injury
What should be done if air embolism is suspected?
Catheter lumens should be clamped and the patient immediately placed in Trendelenburg with a left lateral decubitus position
What are risk factors for development of pulmonary embolism with CVADs?
Diagnosis of cancer
Immobility for long periods of time
Recent surgery or trauma
DVT
Other thrombus elsewhere in the body
What are the 2 criteria that define catheter patency?
The ability to infuse without resistance
Ability to aspirate blood without resistance
What are the 3 key factors that result in the development of vessel thrombus?
Vessel wall damage
Blood flow changes
A systemic alteration in coagulation
What is the recommended catheter to vein ratio recommended by the MAGIC expert panel to reduce the risk for catheter-related DVT?
1:3 catheter-to-vein ratio
What are risk factors for thrombus formation?
Catheter tip position, catheter material, type of infusate, length of catheter duration
What is the recommended volume of flush solution?
At least twice the volume of the catheter (eg 5-10 ml normal saline)
What is an approved thrombolytic agent for CVAD occlusions?
Alteplase
What are the leading causes of intraluminal occlusions?
Drug-heparin interactions
PN formulations with inappropriate calcium-to-phosphate ratios
Lipid residue
What is the key to preventing nonthrombotic occlusion?
The use of a 0.9% normal saline flush between all IV medications, infusions, and heparin
What is catheter pinch-off syndrome?
An intermittent mechanical obstruction related to postural changes caused by catheter compression between the clavicle and the first rib
What are the appropriate disinfecting agents for hub disinfection?
70% isopropyl alcohol
Iodophors
>0.5% chlorohexidine in alcohol solution
What are the 3 categories of CVADs?
Nontunneled
Tunneled
Implanted
