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IV TERAPY & Central Venous Catheters. INSERTION OF PERIPHERAL IV LINE. Aims 1. To gain peripheral venous access in order to: • administer fluids • administer blood products, medications and nutritional components 2. To minimise the risk of complications when initiating IV therapy through:

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IV TERAPY & Central Venous Catheters


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insertion of peripheral iv line
INSERTION OF PERIPHERAL IV LINE

Aims

1. To gain peripheral venous access in order to:

• administer fluids

• administer blood products, medications and nutritional components

2. To minimise the risk of complications when initiating IV therapy through:

• judicious choice of equipment

• careful choice of IV site

• good insertion technique

• aseptic preparation of infusions

key points
Key points

1. Only nurses who have been certified as competent in the insertion of IV cannula will perform this procedure.

2. Where the patient is less than 14 years of age, the IV cannula will be inserted by a medical practitioner. The exception will be in the case of neonates where neonatal trained nurses may insert an IV cannula if directed by a medical officer

3. In the case of two unsuccessful attempts at insertion, the operator will seek the assistance of another experienced nurse for one additional attempt. After a total three unsuccessful attempts the assistance of a medical practitioner will be sought.

phlebitis
Phlebitis

Contributing factors:

• Catheter material • Catheter size

• Site of insertion • Skill of operator

• Duration of cannula • Type of infusion

• Dilution of solution • Host factors

• Insertion in ED • Type of skin prep

• Frequency of dressing change

• Presence of infection

infection
Infection

Contributing factors:

• Contaminated infusions

• Inadequate skin preparation

• Poor technique

• Host factors

extravasation
Extravasation

Contributing factors

• Age

• Site of cannula

• Type of cannula

• Duration of cannula

• IV drug infusions

selection of equipment
Selection of Equipment

Cannula selection

1. Select cannula based on purpose and duration of use, and age of patient.

2. Consider risk of infection and extravasation.

3. Cannulae made from polyurethanes are associated with decreased risk of phlebitis.

4. Steel needles have higher risk of extravasation and should be avoided where tissue necrosis is likely if extravasation occurs.

skin prep
Skin prep

Antiseptic solution - 70% isopropyl alcohol, 0.5 - 1% Chlorhexidine.

Use an aqueous based alternative if there is a known allergy to alcohol

selection of catheter site
Selection of Catheter Site

Choose a suitable vein. In adults, use long straight veins in an upper extremity away from the joints for catheter insertion - in preference to sites on the lower extremities. If possible avoid

veins in the dominant hand and use distal veins first.

Do not insert cannula on the side of mastectomy or AV shunts/Gortex. Transfer catheter inserted in a lower extremity site to an upper extremity site as soon as the latter is available.

In paediatric patients, it is recommended that the cannula be inserted into the scalp, hand, or foot site in preference to a leg, arm, or ante cubital fossa site (Category II)

reasons for inserting central venous catheters
Reasons For Inserting Central Venous Catheters
  • Limited vascular access
  • Administration of highly osmotic or caustic fluids or medications
  • Frequent administration of blood and blood products
  • Frequent blood sampling
  • Measurement of CVP
  • Hemodialysis
type of cvc inserted depends on
Type of CVC Inserted Depends On
  • Patient’s condition
  • Anticipated length of therapy
types of central venous catheters
Types Of Central Venous Catheters
  • Nontunneled central catheters
  • Tunneled central catheters
  • Peripherally inserted central catheters (PICC)
  • Implantable ports
non tunneled external catheters

NON-TUNNELED EXTERNAL CATHETERS

1. Polyurethane

2. Single or multiple lumens

3. Flow varies depending on size and ID

4. Temporary - requires frequent exchanges

5. Easier placement, removal and replacement

nontunneled central venous catheters
Nontunneled Central Venous Catheters
  • Used for short-term therapy
  • Inserted percutaneously
    • Subclavian vein
    • Internal jugular vein
    • Femoral vein
  • Has from 1 to 4 lumens or ports
  • Usually from 6 to 8 inches in length
slide17
Can be quickly inserted
  • Not flexible and may break
  • Dislodged more easily
  • Has the highest infection rate
  • Dressing changes required using aseptic technique
  • Unused ports must be routinely flushed with heparin solution and clamped
tunneled catheters

TUNNELED CATHETERS

1. Single or multiple lumens

2. Flow - variable

3. Long term

4. Easy access (no skin puncture)

5. Cuff - Dacron, vita

tunneled central venous catheters
Tunneled Central Venous Catheters
  • Used for long term therapy
  • Inserted surgically
  • Small Dacron cuff sits in subcutaneous tunnel
  • No dressing is required after cuff heals unless the patient is immunocompromised
  • Initially sutured but removed in 7 to 10 days
  • External portion of the cath can be repaired
peripherally inserted central catheters picc
Peripherally Inserted Central Catheters (PICC)
  • Used for intermediate to long term therapy
  • May be single or double lumen
  • Inserted percutaneously
    • Basalic vein
    • Cephalic vein
  • Threaded into the superior vena cava
  • May be inserted by specially trained RN
picc lines

PICC LINES

1. Silastic or polyurethane

2. Single or double lumen

3. Low flow

4. Short - long term

5. Easy access

slide27
Infusing or drawing blood from smaller gauged PICC may be more difficult
  • Small gauged PICC infuse fluids slower and occlude faster
  • Measure and document external length of PICC with each dressing change
  • Dressing acts as a bacterial shield and helps anchor cath
  • Unused ports must be flushed with Heparin solution and clamped
subcutaneous ports

SUBCUTANEOUS PORTS

1. Single or double lumen

2. Flow - most commonly slow

3. Long term

4. Access requires needle puncture

subcutaneous ports29

SUBCUTANEOUS PORTS

5. Less maintenance

6. Activity is unlimited after site heals

7. Cosmetically more appealing

8. Concealed pocket retards infection (?)

slide30
Minimizes infection
  • Huber needle must be used to access port
  • Must always confirm needle placement before med administration
  • Transparent dressing covers Huber needle and port
  • Unused port is flushed every 28 days with Heparin solution
subclavian vein complications

SUBCLAVIAN VEIN COMPLICATIONS

STENOSIS THROMBOSI PINCH OFF

SYNDROME

Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)

advantages of the right ij

ADVANTAGES OF THE RIGHT IJ

1. Larger

2. More superficial

3. Further from the lung

4. More direct route to the heart

5. Acute and chronic complications are reduced

central venous catheter placement

CENTRAL VENOUS CATHETER PLACEMENT

1. Prep

2. Access

3. +/- Tunnel

4. Secure

slide36
PREP

Alcohol scrub to remove surface oils

Chlorhexidine scrub

Betadine prep (allow to dry)

Ioban dressing and drapes

Maximum Sterile Barrier - Surgical hats, gowns, masks & gloves

3 - 5 min. surgical scrub

Antibiotics (controversial) 30-60 min. prior

Cefazolin (Kefzol, Ancef) 1 gm IV or

Gentamycin 80 mg IV

general nursing care of patient with cvc
General Nursing Care Of Patient With CVC
  • Always follow the institution’s policy and procedure
  • Before insertion, lines are initially flushed with saline
  • During percutaneous insertion of CVC in the subclavian or jugular, place patient in Trendlenberg or have him perform Valsalva maneuver
slide38
After insertion, an occlusive gauze or transparent dressing is applied
  • Blood is aspirated through all lumens to verify patency
  • Chest xray must be performed before use
  • Each lumen of the cath is secured with a Leur-lok cap or CLC 2000 device
slide39
Use only needless system to access ports
  • Infusing devices are used for all infusions
  • TPN is administered exclusively through a dedicated line and port.
  • Catheters must be clamped when removing the cap and when not in use
slide40
Flushing of lines
    • Each lumen is treated as a separate cath
    • Injection caps are vigorously cleaned with alcohol
    • Use 10cc or larger syringe for administration of meds or flush
    • Turbulent flush technique is recommended
slide41
For med administration, use SAS method
  • If port is not to be maintained with a continuous infusion, end with Heparin flush solution
    • Peds 10kg> and adults – 100 units Heparin/ml with preservatives
    • Neonates and peds <10kg – 10 units Heparin/ml without preservatives
    • For specific amounts see procedure
  • Clamp cath while infusing last ½ cc of flush
  • If CLC 2000 used, do not clamp cath until syringe disconnected
slide42
Site assessment and determination of external cath length is performed and documented with each dressing change
  • Tubings are changed per protocol – 72hrs
  • Caps and connections are changed per protocol – 3-7 days
slide43
Dressing changes per protocol
    • Use sterile technique
    • Change when damp, soiled or loosened
    • Change every 7 days if transparent
    • Change every other day if gauze is used
    • Clean skin around insertion site with alcohol in a circular motion. Also clean cath with alcohol
slide44
Use antmicrobial disk if indicated
  • Form a loop of the tubing or cath outside the dressing and anchor securely with tape
  • Label site with date, time and initials
  • Document dressing change, condition of site and length of external cath when appropriate
slide45
For drawing blood specimen
    • Discard initial sample of blood
    • Collect specimen
    • Flush with 10cc saline
    • Flush with Heparin solution if indicated
slide46
Monitor for complications
    • Infection
      • Phlebitis
      • Septicemia or pyrogenic reaction
    • Air embolism
    • Thrombosis/occlusion
    • Extravasation
    • Damaged cath
complications

COMPLICATIONS

1. Acute Procedural

2. Sub-acute Infection

3. Chronic

Infection

Catheter fragmentation

Non-function

complications acute

COMPLICATIONS:ACUTE

1. Spasm 4. Pneumothorax

2. Access failure 5. Malposition

3. Arterial puncture 6. Air embolus

air embolus symptoms

AIR EMBOLUS: SYMPTOMS

1. Respiratory distress

2. Increased heart rate

3. pulse

5. Cyanosis

4. Poore in the level of consciousness

air embolus treatment

AIR EMBOLUS: TREATMENT

1. Left lateral decubitus (Durant’s) Position

2 100% O2

3. Vasopressin if necessary

4. Chest compression

5. Aspiration through catheter +/-

Mortality decreases from 90% 30%

with conventional treatment

complications chronic

COMPLICATIONS:CHRONIC

1. Infection

2. Catheter fragmentation

3. Non-function

risk factors
Risk Factors
  • Four major risk factors are associated with increased catheter-related infection rates:
    • Cutaneous colonization of the insertion site
    • Moisture under the dressing
    • Prolonged catheter time
    • Technique of care and placement of the central line
evidence based strategies selected to reduce cla bsis
Evidence-Based Strategies Selected to Reduce CLA-BSIs
  • Central line-associated bloodstream infections bundle
  • Hand hygiene
  • Maximal sterile barriers
  • Chlorhexidine for skin asepsis
  • Avoid femoral lines
  • Avoid/remove unnecessary lines
hand hygiene
Hand Hygiene
  • Cornerstone of any infection prevention program
  • Many studies have shown that improvement in hand hygiene significantly decreases a variety of infectious complications
  • Insufficient or ineffective hand hygiene contributes significantly to a greater bacterial burden and subsequent spread of microorganisms within the environment
hand hygiene55
Hand Hygiene
  • Use of waterless alcohol-base hand rub
    • Most effective and efficient method for hand antisepsis against bacterial pathogens
  • When hands are visibly soiled, they should be washed with soap and water
efficacy of hand hygiene preparations in killing bacteria
Efficacy of Hand Hygiene Preparations in Killing Bacteria

Best

Good

Better

Plain Soap

Antimicrobial soap

Alcohol-based handrub

maximal sterile barriers
Maximal Sterile Barriers
  • One study found a 6-fold higher rate of catheter-related septicemia when minimal sterile barriers (sterile gloves and small drape) were used instead of maximal sterile barriers

Raad II, Hohn H, Gilbreath J, et al. Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol. 1994;15:231–238.

chlorhexidine for skin asepsis
Chlorhexidine for Skin Asepsis
  • Studies have compared chlorhexidine gluconate (CHG) versus povidone iodine as a skin antiseptic for catheter insertion and routine insertion site care
    • Recent meta-analysis, the use of CHG rather than povidone iodine was found to reduce the risk of CLA-BSIs by approximately 50% in hospitalized patients who required short term catheterization

Chaiyakunapruk N, Veenstra, DL, Lipsky BA, Saint S. Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: a meta-analysis. Ann Intern Med. 2002;136:792–801.

benefits of chg
Benefits of CHG
  • 2% CHG in tincture of isopropyl alcohol has rapid bactericidal activity and is effective within 30 seconds after application versus 2-minute period for povidone iodine
  • CHG provides persistent bactericidal activity on the skin and maintains its activity in the presence of other organic material
  • Minimal systemic absorption
site selection avoid femoral lines
Site Selection: Avoid Femoral Lines
  • Insertion of CVCs can lead to serious and sometimes life-threatening complications, whether of mechanical, infectious, or thrombotic origin
  • Higher rate of infectious complications in study comparing femoral lines versus subclavian lines
    • 19.8% vs 4.5%
avoid and remove unnecessary lines
Avoid and Remove Unnecessary Lines
  • Once placed, there should be periodic, if not daily assessment, of its continued need, with emphasis on prompt removal
empowerment of nursing
Empowerment of Nursing
  • One of the most important steps in preventing CLA-BSIs is to empower the nursing staff to stop the central line insertion procedure if the guidelines were not followed
types of infection

TYPES OF INFECTION

EXIT SITE, TUNNEL/POCKET or CATHETER

1. Cutaneous - pain, erythema, swelling,

+/- exudate

2. Bacteremia - fever, leukocytosis and

positive blood cultures

3. Septic thrombophlebitis - bacteremia,

thrombosis and purulent discharge

infection causative organisms

INFECTION CAUSATIVE ORGANISMS

Staph epidermidis 25-50%

Staph aureus 25%

Candida 5-10%

infection65

INFECTION

1. Septic thrombophlebitis - remove catheter

2. Cutaneous - local treatment

3. Bacteremia -

1. IV antibiotics 48 -72 hours

if improved - keep catheter

if no change, worse or recurs

remove catheter

or

2. Exchange catheter over wire,

85% cure with treatment

infection66

INFECTION

Continue to treat infection for 10 - 14 days

If ineffective - try locking with thrombolytics between antibiotic doses and administer antibiotics through catheters

discharge teaching for the patient with a cvc
Discharge Teaching For The Patient With A CVC
  • Proper handwashing and principles of sterile technique
  • Dressing change procedure and frequency
  • Flushing and cap change procedure and frequency
  • Observation of cath and insertion site
slide68
When to call the physician
    • Temp of 100.5F or greater
    • Chills, dyspnea, dizziness
    • Pain, redness, swelling, or drainage at site
    • Unresolved resistance, pain or fluid leaking while flushing
    • Hole or tear in cath
    • Excessive bleeding at site
    • Change in length of external cath
    • Swelling in neck, face, chest, or arm
slide69
General safety measures
    • No sharp objects near cath
    • Clamp cath when not in use
    • No pulling or tension on the cath
    • Discard syringes and needles in sharps container
    • Activity limitations
    • Use a stress loop
  • Home health referral
discontinuing a cvc
Discontinuing A CVC
  • Follow the institution’s policy and procedure
  • For percutaneous internal jugular or subclavian insertion sites, place patient in trendlenburg position and have him perform the Valsalva maneuver
  • Remove cath and apply pressure with an occlusive dressing over a petroleum gauze
  • Check cath to ensure tip is intact
  • Document how patient tolerated procedure, placement of dressing and cath tip intact