SHORT TERM

- teflon needle-cannulas - (72-96 hours)

Vesicant = ph<5, >9 osmolarity >600 (EX. TPN with D10 or chemotherapy)

Mid line catheters

peripheral VADS
mid-term accesses (up to 3 weeks) Catheter tip is at or below axilla Longer than short peripheral VADS But SHORTER than PICC lines

LONG TERM ACCESS

central venous catheter
introduced via a large vein into the superior vena cava or right atrium to administer fluids ( such as total parenteral nutrition (TPN) , medications, or to measure central venous pressure .

Common insertion sites are:

internal jugular vein subclavian vein femoral vein

NON-TUNNELLED CATHETERS
temporary (non-tunneled) catheters : single/multi-lumen percutaneous short-term
Not used in out-pt setting d/t risk of infection/dislodgement

Non Tunneled Multi lumen AKA CVP

5-7 day dwell time Flush capped lumens every 8 hours per facility protocol Change dressing every 3 days May use for blood sampling May infuse 3 incompatible fluids concurrently

Multi lumen catheter

Highest infection rate Maybe subclavian or femoral Use full barrier when inserting catheter

Temporary (non-tunnelled)

EXAMPLENiagara* Short-Term Dialysis Catheter

Preventing Complications


 

80,000 catheter related bloodstream infections in U.S. each year Cost 2.3 billion to heath care system Most common source of infection is skin

CDC Guidelines for Prevention

Hand hygiene Maximum barrier (sterile barrier for person inserting, assistant, and patient). Chlorhexidine skin antisepsis Daily review of need for CVAD and prompt removal when no longer needed.

PICC
Peripherally Inserted Central Catheter May be inserted by a specially trained nurse May be placed at bedside or under ultrasound guidance

PICC LINE
No dwell time per CDC Flush per facility protocol Change dressing every 7 days May use for blood sampling Do not need order to access

PICC line
May be dual or single lumen Both lumens should be flushed on the same schedule Incompatible fluid maybe infused concurrently

Power PICCs
Maximum Injection Rates PowerPICC* catheters allow injection of contrast media for scans at a maximum rate of 5 ml/sec.

Tunneled catheter
Placed in surgery or IR Tunneled superficially under skinexits chest area Flush per facility protocol Change dressing every 7 days May use for blood sampling Can be managed in out-pt setting

HICKMAN CATHETER
Hickman catheter : a type of CVC used for the long term fluid administration , such as antibiotics , total parenteral nutrition (TPN) , or chemotherapy ; may be a continuous or intermittent administration and may be a single or double lumen

BROVIAC CATHETER
Broviac catheter : a type of CVC similar to Hickman catheter but smaller lumen

Used in children

GROSHONG CATHETER
Groshong catheter (source : Bard Access Systems) : double-lumen, valve

Advantages : decreased risk of blood reflux and gaseous embolism no need to clamp catheter no need for heparin to maintain catheter patency

DIALYSIS CATHETERS
long-term hemodialysis /apheresis catheters : double-lumen tunneled catheters PermCath , Quinton Instrument Co, Seattle.

Implanted Port
No dwell time per CDC Flush with 500 units of heparin every 3060 days when not in use Change dressing and needle every 7 days May use for blood sampling

IMPLANTED PORTS
subcutaneously implanted venous ports (long-term) Port-A-Cath

Implanted port
Dual lumen port Each lumen should be flushed at the same time Each lumen is separate Incompatible fluids may be administered concurrently

Implanted port
Brachial ports Need a inch needle to access May use for blood sampling Smaller than subclavian port

Implanted port
Must be cannulated with hollow core needle Mask and sterile gloves when cannulating port

Implanted port

Implanted port
Cannulation of implanted port

Preventing Complications
Occlusions
Proper flushing maintains patency Follow agency guidelines for CVAD care ( based on manufacturers recommendations and standards developed by national organizations) Remember 42% of catheter occlusions are non-thrombolytic, but caused by mechanical problems( such as: kinked/clamped tubing, air leak, tight sutures around site.)

Flushing
Most central lines need to be flushed with heparin (100units/ml) Heparin reduces line infection rate and maintains patency Controversy exists regarding use of Heparin and HIT

SASH
Saline Administer drug Saline Heparin

Procedure used to administer drugs in many institutions

A BIT ABOUT HIT

Heparin induced thrombocytopenia 1/3 of all hospitalized patients are exposed to Heparin HIT develops in 1-5% of those exposed to Heparin Heparin is avoided or minimized whenever possible by flushing peripheral catheters and sometimes central catheters with isotonic sodium chloride instead of Heparin

FOLLOW YOUR AGENCY PROTOCOL

Blood Sampling
All central lines may be used for blood sampling Use needless vacutainer system

Blood sampling
Discard 10 ml of blood( follow facility policy)

Blood sampling
Attach needless vacutainer system and obtain sample Label sample according to policy

Blood sampling
After sample is obtained: Flush with 10 ml of normal saline and flush with Heparin or resume IV infusion * An additional 10ml of blood must be discarded if collecting a PTT/PT

Preventing Complications
Infection
Replace CVC only when indicated Change dressing when indicated & at least weekly Disinfect site with 2% aqueous chlorhexadine Dont use antibiotic ointment Change tubing per facility protocol

Infection
Infected PICC line site

Why we care
Riley age 13 months Died from sepsis post open heart Origin of infection:
Central lines

References
Cooney M, Heparin induced thrombocytopenia. Critical Care Nurse. 26(6):30-32, December 2006. Intravenous Nursing Society: Standards of Practice 2007 Labeau S, et al. Critical care nurses knowledge of evidenced based guidelines for preventing infections associated with central venous catheters. American Journal of Critical Care. 17(1):65-72, January 2008. Ludeman K. Choosing the right vascular access device. Nursing 2007. 37(9):38-41,September 2007. Oncology Nursing Society: Standard of Practice CVAD Siegel M. Vascular CatheterAssociated Infections. Advance for Nurses 10(2):35-41, 2009. St. James Hospital and Health Centers Patient care policies

Acknowledgements
Special thanks to: Marie Hansel RN MS for use of photos and portions of CVAD presentation