Central and PICC Lines

Care and Best PracticesMary Larson, SN

St. Cloud State University

Mary Larson

Hometown: Atwater, MN

St. Cloud State University Nursing Program: December 21st

Capstone Semester

Preceptor: Jamie Daniel

180 Direct Patient Care Hours, 90 Leadership Hours (40 at Meeker Memorial)

Leadership Project- Teaching

Pre-Quiz

Central Venous Access

Catheters inserted into large veins in central circulation

Tip of catheter threaded to reside in lower third of the vena cava

Chest X-ray to confirm correct placement

Central Venous Access

Indications:

Patients requiring multiple sites for IV access

Patients lacking useable peripheral IV sites

Patients requiring central venous pressure monitoring

Patients requiring total parenteral nutrition

Patients receiving incompatible medications

Patients requiring multiple infusions of fluids, medications, or chemotherapy

Patients requiring long term antibiotic therapy

Patients subject to frequent blood sampling or receiving blood transfusions

Patients requiring a temporary access site for hemodialysis

Patients receiving infusions that are hypertonic, hyperosmolar or infusions that have divergent pH value

Non-Tunneled Percutaneous Central

Venous Catheter

AKA Central Line

Inserted by physician

Subclavian vein of upper chest or internal jugular veins in the neck

Occasionally femoral – higher rates of infection

Measure 7-10 inches (18-25 cm)

1 to 5 Lumens

Used most common: Trauma, critical care, surgery

No recommended dwell time: used for short term, not the catheter of choice

for home care or ambulatory clinic settings

Peripherally Inserted Central Venous

Catheters (PICC)

Long catheter, inserted in vein of antecubital fossa or middle of upper arm

Basilic vein preferred, cephalic used if necessary

Inserted by physicians or specially trained nurses

Length 18-29 inches (45-72 cm), 1-3 Lumens

Optimal dwell time unknown: reported to dwell successfully for months or

even years

Lower rate of Central Line Assoc. Bloodstream Infections (CLABSI) than

Central Lines

Patients requiring lengthy antibiotics, chemotherapy, parenteral nutrition, or

vasopressor agents – benefit from PICC line.

Lumens

Central Line: 1-5

PICC Line: 1-3

Port Designation: (with 3 Lumens)

Proximal

Blood Sampling

Medications

Blood Administration

Medial

TPN

Medications (Only if TPN use in not anticipated)

Distal

CVP monitoring

Blood Admin

High Volume or Viscous Fluids

Colloids

Medications

Catheter Dressings

Center for Disease Control and Prevention (CDC)

Recommendations:

Use either sterile gauze or sterile transparent semipermeable dressing

If pt is diaphoretic or site is bleeding or oozing, use gauze until

resolved

Replace dressing if damp, loosened, or visibly soiled

Do not use antibiotic ointments or creams

Dressing changes:

Short-term CVC sites q 2 days for gauze and at least q 7 days for

transparent

PICC-24 hours post insertion, then transparent dressings q 5-7 days unless

soiled or loose, gauze q 2 days unless wet, soiled, or non-occlusive

>5% Chlorhexidine to cleanse skin during dressing changes

Dressing Changes

Dressing Removal:

Stabilize catheter and Luerlock hub to prevent dislodgement

Separate dressing away from Luerlock hub and toward insertion site

Chlorhexidine should be used to swab in a back and forth pattern for 30

seconds to ensure the skin is clean and disinfected

If patient is diaphoretic with a great deal of fluid present on skin, area should

be scrubbed for 2 minutes to ensure bactericidal activity

During dressing change- assess external catheter length to determine if

migration had displaced catheter tip

Sterile occlusive dressing should cover entire insertion site, suture wing and

at least 2.5 cm of the extension tubing is recommended

Dressing Change Procedure

Gather supplies

Hand hygiene

Don clean gloves and mask (patient)

Remove old dressing (toward insertion site) and discard

Remove gloves, perform hand hygiene, and don sterile gloves

Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck

Cleanse site (chlorhexidine) back and forth motion

Allow to air dry

Secure catheter in place

Apply sterile dressing to site

Document date, time, and initials on new dressing

Document the procedure, any complications, and external catheter length to

patient’s chart

Caps: Needleless Access Devices CDC recommends changing caps at least as frequently as administration sets

No benefit to changing these more frequently than every 72 hours

TPN/Lipids (enhance microbial growth)

Accessing: “Scrub the Hub” for 15 seconds

Types:

Negative Displacement Device

Neutral Displacement Device

Positive Displacement Device

At Meeker Memorial: Baxter Clearlink System (Negative Displacement)

Flushing Lines

A single use syringe should never be used more than once

10 mL syringes should not be divided into several doses and used for multiple

lumens

Never use a syringe smaller than 10 mL

The pressure created by smaller syringes could damage the catheter

Volume: Minimum of twice the volume of the catheter should be used to flush

In general for adults 10 ml is sufficient

0.9% NaCl solution should be used

Frequency: If being used a minimum of q 8 hours, flush with 10 mL NS before

and after every use and for lines in maintenance mode flush with 10 mL NS

every 24 hours.

Flush using a pulsative or “stop-start” technique

Creates turbulence within the catheter to adequately flush medications from the

line

Preventing:

Blood Reflux

Major problem

Catheters are deep in the body, reflux cannot be seen when it occurs

Caused by inadequate flushing, also b/t flushes caused by increased

intravascular pressure (ex: coughing, vomiting) leading to biofilm formation and

buildup, occlusion, and even infection

Prevention Strategy: Know which type of needleless connector is being used.

Negative Displacement (Meeker Memorial – Baxter Clearlink System)

Catheter must be clamped BEFORE syringe is removed

Neutral Displacement

Fluid should remain neutral, therefore clamping can be done before or after syringe removal

Positive Displacement

Important to clamp the catheter AFTER the syringe is removed in order to get displacement

https://www.youtube.com/watch?v=X5wIhmR0SIE

Assessment

Visually examine insertion site daily for erythema, drainage, tenderness,

suture integrity, and catheter position

Routine IV site assessments

Routinely assess dressings (change if necessary)

Daily assessment of need for Central Line and promptly discontinue lines

which are no longer indicated

Nursing staff should be encouraged to notify physicians of Central Lines which

are unnecessary

Documentation The following should be included in the patient’s chart:

Product Name

Date of insertion, inserter

Anatomical location

Catheter depth according to catheter reference markings

X-ray confirmation of catheter tip location

Port designation for infusions/measurements, e.g. TPN, CVP, Medications

Ensures uniform use of lumens

Amount, type, and frequency of flush solution

Dressing and tubing changes

Document exposed catheter length with dressing changes

Site assessments

Every shift

Complications

Catheter removal and application of air-impermeable dressing

References Angiodynamics (2014). Bioflo picc with endexo technology: Directions for use.

Marlborough, MA: Navilyst Medical, Inc.

Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow International, Inc.

Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan for outpatient oncology settings. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/central-venous-catheters.html

Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheter-related infections. Retrieved from http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html

Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.

Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive care unit (non-icu) settings toolkit. Atlanta, GA: Centers for Disease Control and Prevention.

Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based practice and technologies: A continuing educational activity for pharmacists and nurses. Irving, TX: VHA, Inc.

The Nebraska Medical Center (2012). Standardizing central venous catheter care: Hospital to home (2nd ed.). Omaha, NE: The Nebraska Medical Center.

Questions?

Post-Quiz