Parenteral Access Devices Flashcards
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
What are the 3 categories of CVADs?
Nontunneled
Tunneled
Implanted
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
What are the appropriate disinfecting agents for hub disinfection?
70% isopropyl alcohol
Iodophors
>0.5% chlorohexidine in alcohol solution
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
