Cvad insertion competency training
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CVAD INSERTION COMPETENCY TRAINING. Royal Children’s Hospital Melbourne, Australia 2009. INTRODUCTION DEFINITIONS CVAD INDICATION PREPARATION HAND HYGIENE BARRIER PRECAUTIONS CHLORHEXIDINE DRESSINGS IMAGING DOCUMENTATION DAILY REVIEW OF LINE NECESSITY. CONTENTS. INTRODUCTION.

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CVAD INSERTION COMPETENCY TRAINING

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Cvad insertion competency training

CVAD INSERTION COMPETENCYTRAINING

Royal Children’s Hospital

Melbourne, Australia 2009


Contents

INTRODUCTION

DEFINITIONS

CVAD INDICATION

PREPARATION

HAND HYGIENE

BARRIER PRECAUTIONS

CHLORHEXIDINE

DRESSINGS

IMAGING

DOCUMENTATION

DAILY REVIEW OF LINE NECESSITY

CONTENTS


Introduction

INTRODUCTION

  • Central Venous Access Devices are essential for the care of many sick children.

  • Careful consideration of the type of catheter required and the manner in which it is inserted is essential to reduce the risk of infection and thrombosis, and to increase line longevity.


Definitions

DEFINITIONS

  • Peripheral IV Devices:cannulae inserted into small peripheral veins.

  • Midline Catheters:long catheters inserted into peripheral veins with the catheter tip residing at or below the level of the axilla.

  • Central Venous Access Devices (CVAD):catheters whose tip terminates in a central vessel.


Central venous access devices

CENTRAL VENOUS ACCESS DEVICES

  • Central Venous Catheters (CVC)

    • inserted into the subclavian vein, internal jugular vein, external jugular vein or femoral vein

    • ‘tunneled’ CVC HICKMAN, BROVIAC, permacaths, infusaports

    • ‘non-tunnelled’ CVC central lines, vascaths

  • Percutaneously Inserted Central Catheters (PICC)

    • inserted into the basilic vein, brachial vein, cephalic vein or long saphenous vein (may be tunneled)

  • Umbilical Catheters (UVC/UAC):

    • inserted via umbilical vein & arteries of newborn infants


Cvad indication

CVAD INDICATION

  • Considerations for type of CVAD include:

    • therapeutic purpose (including the need for total parenteral nutrition (TPN) or chemotherapy)

    • estimated length of treatment (note: any patient requiring more than seven days of intravenous therapy should be assessed for insertion of a central venous access device)

    • medical history (including any cardiac anomalies or haematological disorders) and previous history of line complications (such as thrombosis)

    • vein status (difficult peripheral IV access should be a flag for early insertion of a central venous access device if the expected duration of IV therapy exceeds seven days)


Cvad indication cntd

CVAD INDICATION CNTD


Preparation sedation assistant

PREPARATION (sedation/ assistant)

  • Sedation/ Analgesia

    • appropriate sedation and analgesia is essential.

  • Assistance

    • all central venous access device insertions should be assisted by a member of staff who has been credentialed in CVAD Insertion or Management.


Hand hygiene

HAND HYGIENE

  • Hand Hygiene should be conducted

    • before & after palpating catheter insertion sites

    • before & after inserting, replacing, accessing, repairing or dressing the device/ line


Hand hygiene1

HAND HYGIENE


Barrier precautions

BARRIER PRECAUTIONS

  • For the operator placing the central line and for those assisting the procedure, barrier precautions means wearing a cap, mask, sterile gown & gloves.

  • For the patient applying barrier precautions means covering the patient from head to toe with a sterile drape, with a small opening for the site of insertion (cover 80-100% of patient).

  • The procedure trolley should also be thoroughly cleaned with Alcohol 70% and fully covered with sterile drapes.


Barrier precautions1

BARRIER PRECAUTIONS

Reproduced with thanks from Cincinnati Children’s Hospital


Chlorhexidine

CHLORHEXIDINE

  • CHLORHEXIDINE:

    • Chlorhexidine 0.5% in Alcohol 70%

    • patient < 1500g & < 1 week old

      •  Chlorhexidine 2% in Aqueous Solution Swab

  • TECHNIQUE FOR CHLORHEXIDINE APPLICATION:

    • press chlorhexidine soaked gauze against the skin & apply a back-and-forth friction scrub for at least 30sec (do not wipe or blot); discard gauze from sterile site

    • allow antiseptic solution time to dry completely before puncturing the site (~ 2mins)


Chlorhexidine1

CHLORHEXIDINE

Reproduced with thanks from Cincinnati Children’s Hospital


Cvad insertion competency training

  • NOTE: All alcohol preparations are flammable. It is imperative that the preparation should be allowed to evaporate completely and that care is taken to avoid pooled pockets of chlorhexidine before exposure to ignition sources such as diathermy. In light of this, tunnelled central venous catheters (hickmans, broviac, permacaths etc) inserted in theatre with the aid of diathermy may use povidone-iodine solutions as an alternative to chlorhexidine, provided it is documented on the insertion notes.


Dressings

DRESSINGS

  • Non-tunnelled CVAD: Tegaderm ®


Imaging tip location

IMAGING – TIP LOCATION

  • UPPER VENOUS SYSTEM

    • Position: lower SVC

    • Approximate Anatomical Landmark:

      • tip position one vertebral body below carina


Imaging lower svc

IMAGING – LOWER SVC

  • LANDMARKS

  • T1 Vertebrae

  • joined by first rib

  • Upper SVC

  • right tracheo-bronchial angle

  • Lower SVC (approximate)

  • right superior cardiac shadow meeting mediastinal edge

  • T6 thoracic vertebrae

  • Approximate Tip Position

  • one vertebral body’s distance below carina


Cvad insertion competency training

Further Advice

  • Tip Too High: positioning the tip too high risks it flicking out of the SVC & upwards with patient arm movement

  • Position CVAD parallel to SVC wall: tips abutting the wall can cause erosion, perforation & predispose to thrombosis

  • Imaging: during continual x-ray screening the CVAD tip will move with the heart beat in the atrium & become still when withdrawn into the SVC


Imaging tip location1

IMAGING – TIP LOCATION

  • LOWER VENOUS SYSTEM

    • PICC/ UVC

      • Position: at/ just below diaphragm

  • CVC/ Vascaths

    • Position: lower IVC

    • Anatomical Landmarks:

      • avoid L1 (renal veins)

      • above L5 (lower border IVC)

      • NB: line parallel to vertebral column above L5


Imaging tip confirmation

IMAGING – TIP CONFIRMATION

CVAD inserted in PICU/ NNU

  • x-ray should be performed prior to use

    PICC inserted in theatre

  • tip position should be determined during insertion with the image intensifier; acceptable positioning should be confirmed before the patient is woken or leaves the operating theatre


Imaging tip confirmation1

IMAGING – TIP CONFIRMATION

CVCs inserted peri-operatively

CVCs inserted for intra-operative use may be used prior to imaging provided the majority of the following criteria are met

  • uncomplicated insertion with no concerns re line position

  • ultrasound used for insertion of IJV lines

  • transduced pressure wave confirms placement in SVC

  • ventricular ectopic beats on ECG with wire placement

  • free aspiration of blood from all three lumens


Imaging tip confirmation2

IMAGING – TIP CONFIRMATION

CVCs inserted peri-operatively

NOTE: if there is any doubt that the CVC is in a central vein an x-ray should be taken prior to use

NOTE: an x-ray must be performed at the end of the case; this can be done in theatre, recovery or PICU/ NNU

NOTE: if re-positioning the CVAD will require a second anaesthetic or sedation it is highly recommended that the x-ray be performed whilst the patient is still anaesthetised


Documentation

DOCUMENTATION

  • CVAD insertion must be documented in the patient’s notes including:

    • date/ time/ indication for CVAD/ brand/ type of catheter/ site of insertion/ depth of catheter placement/ number of attempts/ confirmation of catheter site on CXR


Daily review of line necessity

DAILY REVIEW OF LINE NECESSITY

  • Daily Review: should include how long the line has been in-situ/ necessity for central access/ alternative methods of access and treatment.

  • NOTE: CVADs that are no longer needed for patient care should be removed without delay.


Cvad types

CVAD TYPES

  • CONTENT

    • INFUSAPORTS

    • HICKMANS/ BROVIAC

    • VASCATHS

    • CVC

    • PICC

    • UMIBILICAL CATHETERS


Infusaports

INFUSAPORTS

  • INDICATION

    • > 14days continuous infusate

  • SITES

    • enter venous system at internal jugular vein/ external jugular vein

  • SIZE/ GAUGE


Infusaports1

INFUSAPORTS

  • NUMBER OF LUMENS

    • Single: standard

    • Double: clinical indication

  • VOLUME INFUSABLE

    • N/A

  • TIP LOCATION

    • lower SVC

  • DURATION

    • indefinite


Hickmans broviac

HICKMANS/ BROVIAC

  • INDICATION

    • > 14days continuous infusate

  • SITES

    • internal jugular vein/ external jugular vein

    • femoral vein

    • trans-hepatic


Hickmans broviac1

HICKMANS/ BROVIAC


Hickmans broviac2

HICKMANS/ BROVIAC

  • NUMBER OF LUMENS

    • Single: standard

    • Double/ Triple: clinical indication

  • VOLUME INFUSABLE

    • N/A

  • TIP LOCATION

    • Internal Jugular Vein/ External Jugular Vein: lower SVC

    • Femoral Vein: lower IVC

  • DURATION

    • indefinite


Vascaths

VASCATHS

  • INDICATION

    • Dialysis

    • Haemofiltration

    • Plasmafiltration

  • SITES

    • Femoral: standard

    • Internal Jugular Vein: requires consultant approval

    • Subclavian Vein: requires consultant approval

  • NUMBER OF LUMENS

    • two


Vascaths1

VASCATHS

  • SIZE/ GAUGE

  • VOLUME INFUSABLE


Vascaths2

VASCATHS

  • TIP LOCATION

    • Internal Jugular Vein/ Subclavian Vein: lower SVC

    • Femoral: common iliac vein or IVC

  • DURATION

    • as long as required for temporary extracorporeal therapy


Cvad insertion competency training

CVC

  • INDICATION

    • Up to 14 days of continuous IV access

  • SITES

    • Internal Jugular Vein

    • Subclavian Vein

    • Femoral Vein

  • SIZE/ GAUGE


Cvad insertion competency training

CVC

  • NUMBER OF LUMENS

    • Double: standard

    • Triple: cardiac surgery/ intensive care patients

  • VOLUME INFUSABLE

    • N/A

  • TIP LOCATION

    • Internal Jugular Vein or Subclavian Vein: lower SVC

    • Femoral Vein: lower IVC

  • DURATION

    • CVCs should not be inserted with the intention of more than fourteen days of intravenous therapy


Cvad insertion competency training

PICC

  • INDICATION

    • > 7 days continuous infusate

    • poor venous access/ difficult IV insertion

  • SITES

    • mid arm with ultrasound guidance is the preferred site for anaesthetic placed PICCS to decrease complication rates and increase patient comfort


Cvad insertion competency training

PICC


Cvad insertion competency training

PICC

  • SIZE GAUGE


Cvad insertion competency training

PICC

  • NUMBER OF LUMENS

    • Single Lumen: standard

  • VOLUME INFUSABLE

    • Premicath: < 6ml/hr

    • 3 Fr: 90ml/hr

    • 4Fr: 850ml/hr

    • 5Fr: 1750ml/hr

  • TIP LOCATION

    • Upper Limb Insertion: lower SVC

    • Lower Limb Insertion: IVC (at or just below level of diaphragm)

  • DURATION

    • theoretically: up to one year

    • in practice: often removed earlier secondary to complications


Umbilical lines

UMBILICAL LINES

  • INDICATION

    • UAC

      • blood sampling

      • continuous arterial blood pressure monitoring

    • UVC

      • central venous access

      • central venous monitoring

  • SIZE/ GAUGE

    • UAC

      • < 1200g 3.5Fr

      • > 1200g 5Fr

    • UVC

      • < 3500g 5Fr

      • > 3500g 8Fr


Umbilical lines1

UMBILICAL LINES

  • NUMBER OF LUMENS

    • UVC

      • One Lumen: standard

      • Two Lumens: < 1000g/ extremely sick

  • VOLUME INFUSABLE

    • N/A


Umbilical catheters

UMBILICAL CATHETERS

  • TIP LOCATION

    • UAC

      • High (T6-T9)/ (shoulder  umbilicus + 2cm/)

      • Low (L3-L5)/ (2/3 distance umbilicus to mid-clavicle)

    • UVC

      • IVC at or just below level of diaphragm

      • NOT portal circulation

    • NOTE: tip should not be in RA

  • DURATION

    • UAC/ UVC should not remain in-situ for more than 5-7 days


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