Lecture 01 CVA Devices

Question 1

What are some advantages of a PICC line? (2)

Answer 1

1. Pt can go home It can be kept in longer
2. Easier to access

Question 2

Types of CVAD: Non tunneled catheters are placed where?

Answer 2

Placed in central vein

Question 3

Types of CVAD: Tunneled catheters are placed where??

Answer 3

Under the skin then threaded into a central vein

Question 4

Types of CVAD: Implanted vascular device are placed where?

Answer 4

Device under the skin device with catheter into a central vein

Question 5

Types of CVAD: PICC (Peripheral Vein into Central Circulation) are placed where?

Answer 5

Threaded through peripheral vein into central circulation/vein

Question 6

General indications for CVAD insertion (6)

Answer 6

1. Infusion of concentrated solutions - IV solutions or TPN (parenteral nutrition) with dextrose/glucose concentrations 15 – 25% (max dextrose peripherally is 12.5%)
2. Vasoactive medications such as dopamine and dobutamine
3. Blood products – generally over longer term or larger volumes quickly is possible through central line.
4. Poor or limited peripheral venous access i.e., for longer term antibiotics or blood draws
5. Long term medication or chemotherapy/other vesicant or irritating solutions (hemiport typically used)
6. Hemodialysis – generally short term

Question 7

Principles of Groshong Catheters

Answer 7

1. Negative pressure opens valve inward permitting blood aspiration
2. Positive pressure opens valve outward allowing infusion
3. At neutral pressure valve remains closed reducing risk of air embolism, blood reflux and clotting.
4. Closed-ended catheters do not require heparin

Question 8

Non tunneled multi lumen catheter:

Where is it placed?

When the line is put in, what else do you need to get?

What is it used for?

Answer 8

1. Placed via subclavian or internal jugular vein (In Peds can be placed in groin in PICU setting).
2. Each time you put central line in, you need to know how much went in, there’s cm lines on the line. Also you’ll always have pt get a chest x ray to make sure lines are in the right place before using it. 3.Administer large volumes and multiple fluids
3. Vasoactive medications, antibiotics, blood products, TPN
4. Obtain blood samples

Question 9

What are indications for PICC lines? (8)

Answer 9

General Indications – kept over longer period of time

1. Antibiotics
2. Hydration
3. Pain management
4. Infusion of hyperosmolar/hypertonic fluids
5. Blood transfusion
6. Hyperalimentation (TPN)
7. Some types of chemotherapy
8. Continuous home inotropic therapy (Milrinone, Dobutamine)

Question 10

PICC advantages? (4)

Answer 10

1. Useful for acute care and home care
2. Permits freedom of movement
3. Small, flexible, useful in young or elderly
4. Used to administer fluid and blood draws (if lumen large enough)

Question 11

What are Dialysis Catheters indications?

Answer 11

1. Commonly used in pt with acute renal failures, overdoses
2. Typically used short term
3. Patient requires maturation of dialysis fistula/graft
4. Can be used as bridge as permanent access in those pt who have been depleted of dialysis sites. Only nephrologist can access this.
5. Hard to maintain over longer time frame (infection/septicemia)

Question 12

What are IVAD (Implantable Venous Access Device) indications? (2)

Answer 12

Indications

1. [*] Access site for obtaining blood samples
2. [*] Used for cyclic therapies, such as chemotherapy or antibiotics, and for treatments for chronic or long-term illnesses, such as cancer or cystic fibrosis. Can handle both bolus injections and continuous infusions.

Question 13

Hickman and Broviac (tunneled) catheter

1. Where is it placed?
2. What is it typically placed for? (4)

Answer 13

Open end Catheter (Remember to do ATI)

1. [*] Tunneling is the positioning of a portion of the CVC within the subcutaneous tissue between the venotomy (access to the vein) and exit site. The catheters are externalized at the exit site. Theoretically it provides stability and may protect against endovascular infection from the skin (Dacron cuff).
2. [*] Placed for chemotherapy, long term nutritional support, long term or intermittent therapies

Question 14

What are some Central Venous Access Catheter complication:

Thrombosis

Signs and symptoms? (3)

How is the diagnosis done?

Answer 14

SIgns & Symptoms (3)

1. Swelling / warmth / tenderness of the extremity beyond the insertion site
2. Cyanosis of the face
3. Development of collateral (extra) vessels

Diagnosis is made by ultrasound, venogram or CT angiograph

Question 15

Central Venous Catheter Complications: Air Emoblism

What is it?

Symptoms and Signs?

Management?

Answer 15

Air embolism: entry of air into the vasculature, can occur during insertion, while catheter in place, or during removal of CVCs.

Symptoms and Signs

• Respiratory distress
• Increase HR
• Cyanosis
• decreased BP
• sudden change in level of consciousness
• pt may complain of back/shoulder pain. on auscultation, may hear churning murmur over the precordium.

Management

• Administer O2
• Stay with pt and yell for help
• Pinch off catheter if still inplace
• Cover any open/disconnected catheter ports
• Place pt on left side in Trendelenberg position (Helps keep air in R atrium)

Question 16

How would you care and manage for central line (11 name 5)?

Answer 16

[*] Daily assessment of need for catheter
[*] Aseptic technique – insertion and care
[*] Site care/assessment
[*] Maintain an occlusive dressing - sterile procedure
[*] Minimize breaks in lines/maintain patency
[*] Vigorous scrubs of all hubs, has to be 15 seconds long
[*] Timely tubing changes, varies with facility.
[*] Insertion process and how accessed are extremely important
[*] **Dressings always changed if loose, wet, or non-occlusive**
[*] Otherwise every 7 days if covered by Tegaderm (transparent physiologic dressing) – per facility policy
[*] Use 10 mL syringe or larger!

Question 17

What are hand hygiene procedures when handling central line? (3)

Answer 17

[*] Always wash hands before handling central line tubing
[*] Use clean gloves when accessing central lines in most areas
[*] 15 second “scrub the hub” with alcohol and 15 second “allow to dry” pre accessing needless access port – some facilities require 30 sec for central lines

Question 18

What’s the procedure for Central Line Dressing Change?

(see Craven or ATI and fill answer)

Question 19

What are some Central Venous Access Catheter complication:

Infection

Signs and symptoms? (5)

Answer 19

1. Fever
2. Increased WBC
3. Erythema
4. Tenderness at catheter site
   
   1. Purulent drainage

Question 20

What are some Central Venous Access Catheter complication:

Acute Infection

Signs and symptoms? (2)

Answer 20

1. Occurs 3~5 days after insertion
2. Often due to contaimnation during the insertion procedure

Question 21

What are some Central Venous Access Catheter complication:

Delayed Infection

Signs and symptoms? (2)

Answer 21

1. An infection that occurs more than 5 days after central access device placement
2. Common organism: Staphylococcus Aureus, however others can be causative organism..

Question 22

1. Aseptic technique – bring extra pair of sterile gloves! …and a sterile swab if you noted drainage around site
2. Use mask on self and patient unless VERY cooperative…patient. Have pt face away from the scrub site as well.
3. Always remove transparent dressing toward insertion site to avoid yanking out!
4. Scrub site for 30 seconds – allow to air dry for equal or more time
5. Include wings of catheter (above where sutured) under transparent dressing

Always taking dressing off in the direction of the catheter.