PN Access Devices Flashcards
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
