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Central VenousCatheters


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Overview of Presentation Differentiates between types

List flushing techniques

Discuss insertion

Describe dressing change procedure

Explain procedure for accessing ports

Identifies complications

Recognize nurses role in preventing infection


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http://www.nursing-standard.co.uk/archives/ns/vol14-43/pdfs/4550w43.pdf

Central Venous Catheters


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Types of Central Venous

CathetersNon-tunneled-placed

percutaneouslydirectly into vessel.

Skin sutured at

insertion site.Temporary-usually

less than a couple of

weeks. Example-triple

lumen Arrow


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TunneledSurgically tunneled

through tissue, theninto vein. Often with

cuff that helps

decrease infections

Types-Broviac, Hickman,

Groshong


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What is the difference betweentunneled and non-tunneled?

A Hickman or Broviac are both

examples of tunneled catheters. They

are placed in the OR or ininterventional radiology (if a doctor

inserted it in the ICU, it is not

tunneled!). Nurses do not remove

these.

When you look at a tunneled catheter,

it doesnt have the wings that are

used for sutures. Also, you can feel a

bump a inch or two away from where

the catheter comes out. This is the

cuff, a piece of material that growsinto the tissue to keep microbes out.

Wings!

No Wings!

This is

the cuff

This is not atunneled

catheter

This is a tunneled catheter


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Ports Implanted under skin,

thus must beaccessed.

Decreased infection

rates

May last months-years

Types-Passport, port-a-cath


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Non coring needle Implanted ports are to

be accessed by non-coring needles only

The use of standard

blunt angle needlescan lead todegradation of the port

and potential forembolization of portmaterials


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PICCsPercutaneously placed

central catheters

Long catheters placed in

arms, legs

Comfortable to patient,

but high complication

rate from infections,catheter rupture


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Flushing Central Venous

Catheters Identify catheter type correctly

Use alcohol to prep

Smaller than a 10 ml syringe will exert

higher pressure on the catheter. Alwaysapply minimal force to activate a flush.

Must use CVL Heparin order sheets toobtain heparin and chart flushes on MAR.


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Careful!!! Dialysis catheters are locked

with 5000 unit/ml heparin foreach lumen. Dialysis catheterscan only be accessed by a

non-dialysis RN after an orderby the renal fellow orattending. Dialysis cathetersshould only be removed bynurses trained to do so (ICUand Dialysis RNs)


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Insertion Must use full barrier

precautions (mask, hat,gloves, gown, full sterile

sheet)

The physician will confirm

correct placement. Methods

for confirmation include

imaging, transducing and

ABG sampling


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Maintenance All CVCs must be assessed initially and every 2 hours

thereafter. Document any changes. Tubings, caps are changed q 72 except for TPN with

lipids, which is changed q 24

If new CVL is inserted, new tubing must be used. Leur-lock caps must be used at all times except for

transduced catheters (i.e. CVP)

Large bore catheters used for introduction of pulmonaryartery catheters should be removed or changed to

smaller lumen catheters when pulmonary artery catheter

is no longer needed


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Dressings Change opaque dressings q 24

Change transparent dressings every 7days or when no longer occlusive

Aseptic technique-use CVL dressingkit with mask

Notify MD and Infection Control ofsuspected infection

Use Chloraprep and Biopatch


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Removing CVCs RNs can only remove non-tunneled catheters.

Only ICU and dialysis RNs competent to do somay remove dialysis catheters.

Position patient with head as low as possible.

Remove sutures and pull line with steady motion aspatient holds breath or during expiration.

Assure tip is present. For PICCs, see measurementobtained at time of insertion.

Hold pressure until bleeding stops, apply dressing.


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Complications-Occlusion Follow occlusion

management protocolas per unit policy

Consult with MD andclinical pharmacist to

decide correct solution

(for thrombus or

precipitate)


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Infection ControlDid you know?

Up to 20% of patients with blood stream infections

(BSI) from central lines die?

The cost of each BSI can be up to 30,000-much ofwhich the hospital does not get reimbursed for?

Grouping interventions together can decrease

infection rates than implementing singleinterventions alone? This is called a bundle

Institute for Healthcare Improvement, 2006


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What is a bundle???A bundle is a selected set of

elements of care distilled fromevidence-based practice

guidelines that, whenimplemented as a group, have

an effect on outcomes beyond

implementing the individualelements alone

Institute for Healthcare Improvement, 2006


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Central Line Bundle Hand Hygiene

Maximal Barrier Precautions Upon Insertion

Chlorhexidine Skin Antisepsis

Optimal Catheter Site Selection, withSubclavian Vein as the Preferred Site forNon-Tunneled Catheters

Daily Review of Line Necessity with PromptRemoval of Unnecessary Lines


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Insertion Site selection-recommended site in adults is the

subclavian site. For pediatrics-no data. Full barrier precautions should be used-MDs

should use gown, hat, gloves and mask. If you

are in and out of the room, wear a mask. If you

stand there the entire time, you should use full

barriers, too.

Antibiotic impregnated catheters recommended


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Flushing When flushing multiple lumens, do not use

the same syringe for flush.

Properly prep leur-lock injection site-all the

time.

Use positive pressure flush to keep line from

clotting.

Meticulous technique importantone slip upcan introduce pathogens into your patients

bloodstream.


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Remember.Try not to let the end of

the tubing hit thefloor.

Or take the cap off with your teeth.


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http://www.learnovation.com/johnwise_samples.htm

You cant be

too clean!!!

And, wash your hands!!!!!!!!


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Test!!1. Monitor CVL site and catheter

connections on initial shift assessmentand assess thereafter:

a) At minimum every 8 hours.b) At minimum every 2 hours.

c) At minimum every 4 hours.

d) CVLs only need to be assessed on initial shift

assessment.


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Test!2. Personnel involved with CVL placement

must adhere to maximum barrierprecautions which includes:

a) Sterile gloves and a maskb) Sterile gloves, large sterile drape and a mask

c) Sterile gloves, mask, sterile gown and cap

d) Sterile gloves, mask, sterile gown, cap, andlarge sterile drape


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Test!4. TRUE or FALSE Large bore catheters used

for introduction of pulmonary artery cathetersshould be removed or changed to smaller

lumen catheters when pulmonary artery

catheter is no longer needed


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Test6. TRUE or FALSE Both the adult and

pediatric IV flush orders contain a sectionthat allows MDs to order 0.9 sodium

chloride flush only.


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