Seminar #10: Central Venous Access Devices Flashcards
VAD Selection - which one to choose based on duration of therapy?
PVAD, PICC, or CVAD
less than 7-10 days = PVAD
7 days - 1 month = Non-tunneled CVAD
>1 month, <1 year = PICC
More than 1 year/LT = Tunneled CVAD, IVAD
What is a PICC?
- inserted in periphery in cephalic, basilic, or median cubital vein above ACF (antecubital fossa)
- tip of catheter rests in lower portion of distal superior vena cava
- usually inserted using ultrasound
- valved/non-valved
- single, double, or triple lumen
- for > 1 month, >1 year
Valved PICC (no clamp)
- venous access device w/ internal (integrated) valve/device located @ either proximal or distal end
- valve allows infusion + aspiration through VAD, but remains closed when not in use –> prevents back flow & providing a safety mechanism
- no need for routine clamping / heparinizing
Non-tunneled CVADs - what are they?
- for ST + emergent therapy (e.g., resuscitation, CVP monitoring)
- placed in internal jugular, external jugular, or subclavian vein (rarely femoral vein)
- inserted surgically, verified w/ cxr, sutured in place
- requires sterile dressing
- single, double, or triple lumen
- for <7 days d/t incr risk of infection (but up to 1 month)
Non-Valved PICC (with clamp)
- venous access device without internal (integrated valve) or device
- has clamp to prevent reflux or back flow of fluid contents/blood
Tunneled CVADs - what are they?
- for** LT intermittent/continuous access**
- placed in subclavian or internal jugular vein
- proximal end tunneled subcu from insertion site (10-15cm), brought thru skin @ exit site
- have **dacron cuff **on tunneled portion of catheter that is placed under skin above exit site
- in 3-4 wees, granulation tissue will grow onto cuff & create seal, which helps catheter from slipping out & acts as barrier to infection
- inserted via surgical incision in OR/medical imaging under fluoroscopy
- no dressing needed once healed
- single, double, triple lumen
- req heparin flush solution to maintain patency - can be left in place indefinitely (if no infection, blockage, or thrombosis)
- for tx >1 year
What is an IVAD?
implanted vascular access device
- IVAD port consists of reservoir (hollow metal disk w/ self-sealing membrane), and catheter
- distal end of catheter placed in **distal third of superior vc **
- surgically implanted by vascular surgeon into small subcu pocket usually on upper anterior chest (line tunneled to vein, secured w/ sutures)
- decr risk of infection
- no dressing req when not being used
- when in use, need: aseptic dressing over Huber needle, site, tubing
- port access using “Huber needle” (w/ attached extension tubing) w/ sterile technique
- req heparin flush solution (5mL) to lock line
- for LT IV therapy, usually more than 1 year
What to look for when assessing an IVAD
- observe for dislodging of catheter tip (neck/ear pain, on affected side, gurgling sounds, palpitations)
- observe s/s dislodged part (free movement of port, swelling, difficulty accessing port)
- usually flushed q8 weeks when not in use
- req heparin flush solution to maintain patency
What is a hemodialysis catheter used for?
- temp access needed for hemodialysis (e.g., emergency/waiting for AV fistula to heal)
- usually inserted into internal jugular/subclavian vein & into superior vena cava
- 2 types of tunneled catheters: uncuffed (ER, <3 months), cuffed (>3 months)
- put in by nephrologist, surgeon, or radiologist in xray department/OR
- catheter held in place by stitch on skin
- if catheter used permanently, stich may be removed once catheter firmly in place
What is the importance of CVAD Tip Position?
- subclavian + jugular vein CVADs: tip of catheter should be in lower third of superior vena cava
- catheters positioned w/in heart have incr risk of mortality
- tips positioned perpendicular to vein wall have incr risk of vessel erosion, hydrothorax, hydromediastinum, tamponade, and extravasation
- never use CVAD unless tip position confirmed
CVAD Ports/Port Openings - what to know?
- each lumen treated as separate catheter
- multi-lumen catheters have diff port openings @ end of catheter
- each lumen has diff colour hub (e.g., red for blood, white for TPN)
- proximal = good for blood draws
- distal + medial = good for medications + running fluids
What are the indications for CVAD?
administering:
- IV fluids + blood products (including large volumes of IV quickly)
- medications (including vasopressor/vasodilator therapy)
- vesicants (e.g., chemo)
- irritant meds (e.g., ceftriaxone, pantoprazole)
- solutions w/ extreme pH values (e.g., vancomycin)
- hypertonic solutions (e.g., TPN)
- obtain venous bld samples
- monitor central venous pressure (CVP)
- provide access for pulmonary artery catheters / transvenous pacemaker
- for hemodialysis access
Administering Medication through CVAD - Considerations?
- many meds are irritating to peripheral vein, so better given thru central line
- check parenteral policy b4 admin
- check compatibility of med w/ infusing solution
- check VAD patency of CVAD b4 med admin
- flush b4 & after med with NS
- flush b/t meds given through same lumen
Administering TPN through CVAD - Considerations?
- CVAD always used for TPN
- in-line filter req for TPN
- needs dedicated line
- white port of multi-lumen CVAD may be port used for TPN
- solutions prepared by pharm daily
- solutions need to be checked w/ another RN prior to hanging to ensure solution matches daily doctor orders
- solution/tubing changed q24h
When would you use PICC to draw blood?
- pt’s peripheral veins no longer accessible
- clinically significant reasons (e.g., risk of hemorrhage, needle phobia, client refusal)
What are the concerns w/ drawing blood from CVAD?
- incr risk of catheter-related infection
- CVAD occlusion
Which lumen should be used when drawing blood from CVAD?
- best to use largest lumen each time
- if multi-lumen CVAD, leave red one for blood
What are IV Manifolds?
- used in ICU
- used to allow compatible medication to infuse simultaneously in same lumen of IV
Role of Nurse Caring for Pt w/ CVAD
- ensure** asepsis **w/ all central lines + venous access ports
- assess site (inspect + palpate) for redness, drainage, swelling, pain, tenderness, warmth, numbness, paresthesia
- q1h for continuous infusion CVAD
- qshift for saline/heparin locked CVAD
- non-tunneled CVADs, ensure line is secured w/ sutures - ensure patency of all CVADs
- follow agency policy for frequency of patency checks + flushing
- intermittent CVAD infusions, lock after final flush
- IVAD only: qshift + non-coring needle changes
- if line not flushing properly/unable to aspirate, notify IV team + label “do not use” - assess** CVAD dressing + prevent infection**
- check external length of PICC catheter to ensure correct placement per agency policy
- PICC measured q24h, with every dressing change, prn
- if >2cm diff from initial measurement, report to MRP/IV team
- CVAD external length usually not measured
CVD continuous infusions: should they have a needleless cap connected to hub of lumen?
not necessary for continuous infusions thru PVAD/CVAD (open system), but is required for closed system, e.g., primary infusion, no ports in tubing
best practice = using closed system, not disconnecting line
What are the potential CVAD complications?
- infection
- air embolism
- occlusions: thrombotic, chemical, mechanical
- phlebitis, thrombophlebitis, infiltratoin, extravasation
- catheter fracture
- catheter embolism
- pulmonary embolism
- catheter migration
- pneumothorax/hemothorax
- arrhythmia
Catheter-related infection/sepsis - s/s, diagnosis + tx?
s/s:
- local: redness, tenderness, purulent drainage, warmth, edema @ insertion site
- systemic: fever, chills, malaise
- other s/s suggesting local/bloodstream infection
diagnosis:
- altered VS (incr temp, incr HR, incr RR, decr BP), altered LOC
- abnormal labs (CBC, bld culture, lactate)
tx:
- local: warm, moist compresses + culture of drainage from site; catheter removal if indicated
- systemic: IV fluids, abx, sepsis protocol, catheter removed if indicated (tip sent to lab for culture)
What is lactate?
unstressed = 1-1.5 mmol/L
- metabolite of glucose prod by tissues in body in anaerobic conditions
critically ill: >2 mmol/, > 4 mmol/L = need for immediate resuscitation + ICU admission
- can lead to lactic acidosis (> 5mmol/L)
- results from overproduction of lactate, decr metabolism of lactate/both
Guidelines for preventing CVAD infections
- hand hygiene
- mechanical scrub of needleless cap b4 each use
- don’t palpate after application of anti-septic
- monitor catheter sides visually
- if diaphoretic/ if site bleeding/oozing, use gauze dressing
- use CVC w/ min # of ports/lumens
- remove asap if not needed
- use antiseptic/abx impregnated central venous catheters + chlorhexidine impregnated sponge dressings
