Week 9 - CVAD Flashcards
What are the different types of CVADS?
- PICC
- non-tunnelled CVADS
- tunnelled CVAD
- IVAD
- hemodialysis catheter
How long can a PICC be used for treatment?
more than 1 month but less than 1 year
Where are PICC lines inserted in the periphery?
- cephalic
- basilic
- medin cubital vein
where does the tip of a PICC rest?
- lower portion of the distal superior vena cava
how many lumens can a PICC be?
- single lumen
- double lumen
- triple lumen
Where are the 3 places a non-tunnelled CVADS can be placed?
- jugular
- subclavian
- femoral (not common)
when are non-tunnelled CVADS used?
short term/ emergent therapy
how long can a non-tunnelled CVADS be left in place? why?
7 days to a month b/c of increased risk of infection
where is a non-tunnelled CVADS placed?
- internal jugular
- external jugular
- subclavian vein
- rarely in femoral vein
Who inserts a non-tunnelled CVADS? What needs to be done after?
- surgically sutured by a physician
- placement needs to be verified by CXR
what lumens can a non-tunnelled CVADS be?
- single lumen
- double lumen
- triple lumen
What do non-tunnelled CVADS require?
- sterile dressing
- heparin flush solution to maintain patency
where is a percutaneous CVAD inserted?
internal jugular or subclavian vein
When are tunnelled CVADS used?
- long term intermittent
- continuous access
- treatments expected to last more than 1 year and long term
where is a tunnelled CVADS inserted?
- subclavian or internal jugular vein
in regards to a tunnelled CVADS where is the proximal end placed?
- tunnelled subcutaneously from the insertion site (10-15cm)
- brought out through skin at an exit site
What does the tunnelled portion of a tunnelled CVADS have?
Dacron cuff
where is a dragon cuff placed in regards to a tunnelled CVADS?
under the skin just above the exit site
what will happen to the dacron cuff in 3-4 weeks in regards to a tunnelled CVADS?
- granulation tissue will grow onto cuff
- creates a seal
- seal helps keep catheter from slipping out/ acts like a barrier to infection
how is a tunnelled CVADS inserted?
surgically in OR or in medical imaging under fluoroscopy
what lumen size can a tunnelled CVADS be?
- single lumen
- double lumen
- triple lumen
what does a tunnelled CVADS require?
heparin flush solution to maintain patency
is a dressing required for a tunnelled CVADS?
- required until site is healed
- no dressing needed at home
when is an IVAD used?
- long term IV therapy
- treatments expected to last more than 1 year
what does the port of an IVAD include?
- reservoir
- hallow metal disk with a self sealing membrane
- catheter
where is the distal end of an IVAD normally placed?
- in the distal third of the superior vena cava
how is an IVAD placed?
surgically by vascular surgeon
where is an IVAD surgically placed?
- on the upper anterior chest
- line is tunnelled to the vein and secured with sutures
does an IVAD have an increased risk for infection?
no, it has a decreased risk
does an IVAD require a dressing?
- no dressing required when not being used
- if being used needs aseptic dressing over needle, site, tubing
what is used to access the port on an IVAD?
- huber needle with attached extension tubing
can a student access/ de-access an IVAD?
no, you need further education to do this
When assessing an IVAD what are you looking for?
- dislodging of Catheter tip
- signs of dislodged port
how often does an IVAD need to be flushed? What do you use to flush it?
- flushed at least every 8 weeks when not in use
- heparin flush
what are the signs of a dislodging catheter tip in regards to an IVAD?
- neck or ear pain
- an affected side
- gurgling sounds
- palpitations
what are the signs of a dislodging port in regards to an IVAD?
- free movement of port
- swelling
- difficulty accessing port
When is a hemodialysis catheter used?
temporary access needed for hemodialysis
Where is a hemodialysis catheter inserted?
internal jugular or subclavian vein then into superior vena cava
what are the 2 types of tunnelled hemodialysis catheters?
- uncuffed
- cuffed
when would you use an uncuffed tunnelled hemodialysis catheter?
in an emergency or treatment is less than 3 months
when would you use a cuffed tunnelled hemodialysis catheter?
used if treatment is longer than 3 months
who inserts a hemodialysis catheter?
nephrologist, surgeon or radiologist in x-ray department or operating room
now is a hemodialysis catheter kept in place?
by a stitch on the skin
How is a hemodialysis catheter kept in place if used permanently?
stitch may be removed once catheter is firmly in place
what are indications for a CVAD?
- administer:
- IV fluids/ blood products
- medications/ irritants
- vesicants
- solutions c extreme pH values
- hypertonic solutions - obtain venous blood samples
- monitor central venous pressure
- provide access for:
- pulmonary artery catheters
- transvenous pacemaker
- hemodialysis
What is used to administer total parenteral nutrition?
CVAD
What is used to administer PPN?
peripheral line
in regards to a CVAD what dis needed to administer TPN?
- in line filter
- dedicated line
What port is used on a multi-lumen CVAD for TPN?
white port
Who prepares TPN solutions?
pharmacy daily
What does CVP stand for?
Central Venous Pressure
CVP is the pressure measured in what?
vena cava near the right atrium
Where is a CVAD typically placed?
subclavian or jugular vein
What is the normal range for a CVP?
3-8cm H2O or 2-6mmHg
what are the indications for a CVP?
- hypotension refractory to fluid resuscitation
- severe sepsis
describe hemodynamic monitoring
catheter inserted into pulmonary artery
What does hemodynamic monitoring include?
- measures of heart rate
- arterial pressure
- cardiac filling pressures/ volumes
- cardiac output
- mixed venous oxygen saturation
what is a transvenous pacemaker
- potentially like saving intervention used primarily to correct profound bradycardia
in regards to transvenous pacemakers what can they be used for?
treat symptomatic bradycardia that doesn’t respond to transcutaneous pacing or to drug therapy
where is a transvenous pacemaker placed?
pacing electrode threaded through vein into right atrium, right ventricle or both
what do you do if there is residual blood left in the cap after flushing a CVAD?
perform a needless cap change
what supplies do you need to perform a needless cap change?
- new sterile needless cap
- alcohol wipes
- 10mL flush syringe
What are the steps in forming a needlessness cap change?
- prep needleless cap keeping sterile
- attach NS/ prime line
- scrub hub around old needleless cap end
- attach to port c alcohol for 30sec
- request client turn head away from line
- ensure line clamped
- remove old needleless cap/ replace c primed new one
- patency check/ flush/ restart infusion
How do you know if a line is occluded?
- no blood able to be aspirated
- sluggish blood return
- resistance to flushing
- fluids will not infuse via gravity
- frequent occlusion alarms
- infiltration/ extravasation
- swelling
How often do you need to flush a PVAD that is not in use?
Q24hrs
how often do you need to flush any CVAD that is not in use?
once a week
how often do you need to flush an IVAD that is not in use?
assess patience and flush q1-3 months
When changing a CVAD dressing what do you assess for?
- signs/ symptoms of infection/ complications
- external length marked on catheter
for a CVAD dressing if there is drainage, blood or moisture under the dressing how often does it need to be changed?
Q7days and PRN
for a CVAD dressing if there is drainage, blood or moisture under the dressing and gauze is placed over site how often does it need to be changed?
change 48hrs of placement of gauze
What are potential CVAD complications that could happen during insertion?
- arrhythmia
- arterial puncture
- pneumothorax
- hemothorax
- hydrothorax
- injury to brachial nerve plexus
- cardiac perforation
- central venous perforation
- catheter migration/ malposition
- intolerance reaction
What does hydrothorax means?
infiltration of IV fluids in the pleural space
What are potential CVAD complications that could happen after insertion?
- pulmonary embolism
- phlebitis
- infection
- total or partial occlusion
- venous thrombosis
- extravastion
- infiltration
- catheter fracture
what is a venous thrombosis?
- blood clot between the catheter and the vein or an intraluminal clot
What is one complication that can occur during both insertion and post insertion of a CVAD?
air embolism
What are infusion related complications in regard to a CVAD?
- circulatory overload
- speed shock
- allergic reactions
- particulate matter
What are signs and symptoms of a local catheter related infection/ sepsis?
- redness
- tenderness
- purulent drainage
- edema at the insertion site
What are signs and symptoms of a systemic catheter related infection/ sepsis?
- fever
- chills
- malaise
What is the diagnosis used to determine catheter related infections/ sepsis?
- increased temp
- increased HR
- increased RR
- decreased BP
- altered LOC
- abnormal lab results
what is the treatment for local catheter related infection/ sepsis?
- warm moist compresses
- culture of drainage from site
- catheter removal if indicated
what is the treatment for systemic catheter related infection/ sepsis?
- IV fluids
- antibiotics
- sepsis protocol
- catheter removal if indicated
what are the guidelines for preventing CVAD infections?
- hand hygiene
- clean needleless cap
- palate insertion site
- inspect insertion site
- remove IV when no longer needed
what 2 conditions must be simultaneously present for air to enter the vascular system?
- pressure gradient between vascular space/ atmospheric air
- direct line of access to the blood vessel
what does the severity of an air embolism depend on?
- volume of air that enters the vessel
- rate of entry
- client’s position at the time of entry
what are client dependent considerations in regards to air embolisms?
- age
- size
- existing disease process
there is not an exact volume of air that is significant but in general what amount is considered potentially lethal for air embolisms?
greater than 50mL
in regards to air embolisms the rate of entry affects what?
potential/ severity of resulting morbidity/ mortality
what are signs and symptoms of an air embolism?
- sudden onset of dyspnea
- continued coughing
- breathlessness
altered mental status
shoulder/ chest pain - lightheadedness
- hypotension
jugular vein distension - feeling of impaired doom
what is the treatment for an air embolism?
- close/ clamp existing catheter
- occlude puncture site of catheter that has been removed
- trandelenburg left lateral position
- apply O2
- notify MRP
What are the different types of CVAD occlusions?
- thrombotic occlusion
- chemical occlusion
- mechanical occlusion
what percent of occlusions are thrombotic occlusions responsible for?
58%
what percent of occlusions are chemical occlusions responsible for?
42%
describe a thrombotic occlusion
thrombus that attached to CVAD and has also adhered to vessel wall
what are the signs and symptoms of a thrombotic occlusion?
pain, edema and engorged peripheral veins in:
- neck
- shoulder
- chest
what is the treatment for a thrombotic occlusion?
- thrombolysis therapy
- systemic anti-coagulation with/ without CVAD removal
What are the different types of catheter thrombosis?
- intraluminal clot
- fibrin tail
- mural thrombus
- fibrin sheath
describe an intraluminal clot in regards to the different types of catheter thrombosis?
- resistance upon aspiration
- decreased ability to infuse fluids
describe an fibrin tail in regards to the different types of catheter thrombosis
resistance upon aspiration as tail gets sucked back over opening when blood aspirations attempted
- no resistance when flushing
describe an mural thrombus in regards to the different types of catheter thrombosis
- depending on location may/may not be symptomatic upon syringe assessment
- result in partial/ complete occlusion of vein
what are signs and symptoms of a mural thrombus?
- swelling
- pain
- tenderness
- engorged vessels
describe a fibrin sheath in regards to the different types of catheter thrombosis
- inability to aspirate
- difficult to withdraw blood
- resistance/ inability to infuse fluids
- creates sock over end of catheter or whole length
describe a chemical occlusion
occurs suddenly during admin due to drug, mineral or lipid residue precipitate
what are some risk factors in regards to chemical occlusions?
- recent infusion/ incompatible drugs
- medications with high risk for precipitation
- high concentrations of calcium, phosphorus in parental nutrition
what are signs and symptoms of a chemical occlusion?
- line is sluggish/ difficult to flush
- vary depending on type of occlusion
what is the treatment for chemical occlusion?
- depends on cause
- consult pharmacist
what are the causes of mechanical occlusions?
- kinked tubing
- cracks/ leaks in CVAD
- constriction of CVAD due to improperly placed sutures at insertion site
- catheter tip migration
- malposition of catheter
- closed clamp
- client position
what are the signs and symptoms of a catheter embolism?
- palpitations
- arrhythmias
- cough
- dyspnea
- thoracic pain not associated c client’s diagnosis/ comorbidities
what are some prevention methods you can do in regards to catheter embolism?
- don’t withdraw catheter through needle during insurtion
- never use vascular access devices for power injection
- size of flush syringe should be appropriate for type of CVAD/ intended use
what are interventions that can be done in regards to a catheter embolism?
- upon removal inspect all catheters for damage/ fragmentation
- notify MD / treat symptoms
- save catheter/ report
what are the signs and symptoms of a pulmonary embolism?
- anxiety
- dyspnea
- tachypnea
- pallor
- cough
- hemoptysis
- diaphoresis
- chest pain
- lightheadedness
what are prevention measures that can be done in regards to pulmonary embolism?
- never irrigate catheter if IV not flowing
- use in line filters
- thoroughly inspect medication/ solution containers
what are some treatments for pulmonary embolisms?
- strict bed rest in semi fowlers position
- notify physician ASAP
- monitor vital signs
- administer O2
- assess CVC for patency
describe Catheter migration
CVAD catheter migrates in/out changing position of tip
what are signs/ symptoms of a catheter migration?
- sluggish infusion/ aspiration
- edema of chest/ neck
- client complaint of gurgling in ear
- dysrhythmias
- increased external catheter length
what are treatments for catheter migration?
- stop infusion
- re-confirm placement with CXR
- consult c trained RN/ MRP
describe arrhythmias
CVAD advanced into right atrium risk of irritating heart causing arrhythmia
what are signs and symptoms of an arrhythmia?
- abnormal heart rate and rhythm
- palpitations
what are some treatments for arrhythmias?
- oxygen
- remove cause
- treat symptoms
What do you do if you suspect an occlusion (mechanical, thrombotic, or chemical)?
- stop infusion/ injection
- check IVAD for correct
needle position/ replace non-coring needle - have patient
- take deep breaths/ cough
- change positions
- raise/ Lower arms - flush VAD c 1-2mL NS
- reassess if not able t aspirate label catheter do not use
- contact MRP or IV nurse
What do you do if you suspect catheter malposition?
- stop infusion/ injection
- change dressing
- do not re-insert catheter
- measure/ document new external length
- if more than 2cm label catheter do not use
- do not remove
- contact MRP or IV nurse
