IV THERAPY PART 4

1. IV THERAPYPART 4 Alternative Access & Complications Catherine Luksic, BSN RN

2. Alternative access routes • 1. Central Venous Lines - percutaneous -<60 days, subclavian or internal jugular veins - Single, double, triple, quad-lumen - Sutured in place, Sterile dressing change q.7 days *check policy….may be q 48-72 hr. - May require daily heparin flush **check policy • 2. Tunneled catheters – Hickman, Broviac, Groshong - Percutaneous, tunnelled under skin - Single, double, or triple lumen - Long term use 1-2 years • 3. PICC lines - Peripherally Inserted Central Catheter - placed peripherally, longer term use

3. Alternative Access Routes • 4. Implantable Ports • Single or double lumen • Single or double port • Metal chamber connected to silicone catheter • POC (port-a-cath) • Requires huber needle to access • Change needle q. 5-7 days • *check policy first

4. 5. Tesio Catheter • For hemodialysis use ONLY • Do NOT access, flush, aspirate or administer meds via Tesio • For dialysis staff only ! • Require heparin

5. Central Venous Line • Most common use = hospital • Usually have multiple lumens • Advantages: • Can be inserted at bedside. • Easy to use • Multi-lumen • Disadvantages: • Requires sterile dressing changes (check policy) • Risk of infection • May require daily heparin flush (if not used continuously) • Requires activity restrictions

6. Triple Lumen Catheter (TLC)Central Venous Line (CVL)

8. Central Venous Lines

9. Tunneled Catheters • Placed surgically in OR • Tunnel is made from surgical site near the subclavian to an exit wound further down on chest. (2 surgical wounds) • Cuff forms a barrier under the skin - stabilizes catheter and prevents bacterial migration into bloodstream • examples : Broviac, Hickman, Groshong

10. Groshong Catheter

11. Implanted Ports • Relatively common • Placed and removed in OR • Common use = chemo • Port is placed in a surgically made “pocket” and sutured in place. Catheter extends into vein from this port/reservoir. • Must be “accessed” for use w/ huber needle • *LPN may NOT access POC

12. Port a Cath (POC)

14. PICC Lines • Can be 20x longer than peripheral cath • Can be used up to 1 year (usually less) • Common use = long term antibiotic therapy; TPN • Must be confirmed by xray before use • Advantages: • Can be inserted by specially trained nurse at bedside • Low infection rate • Disadvantages: • Requires daily flush • Limits activity (external catheter) • Cannot use for high pressure infusions

15. PICC

16. PICC Lines • FLUSHING – used to maintain patency of the line. • Dictated by agency policy. • Most commonly normal saline, followed by heparin. (Volume determined by manufacturer, usually 5-10cc). • Check for allergies, incompatability, bleeding, etc. • Check policy re: heparin use • MUST USE 10cc SYRINGE

17. PICC LINE CARE • CXR MUST BE DONE TO CONFIRM PLACEMENT • ROUTINE IV SITE MONITORING PLUS: • ARM CIRCUMFERENCE (DO NOT USE FOR BP) • TEMP ↑, RESP STATUS, CARDIAC IRREG • EXTERNAL CATH LENGTH – measure, check markings • PATIENT EDUCATION

18. Central Lines • SCRUB THE HUB • 15 seconds • APPLY ANTIBACTERIAL CAP BETWEEN USES

20. Central line dressing change • Change as needed and according to institution policy • q 48-72 hr for CVC or…. • Q 7 days for CVC **check policy ! • Q 7 days for PICC • Must be performed as sterile procedure • Inspect site at each change

22. Central Line Dressing Change • Cleanse from insertion site outward for 4-6 in area • Cleanse site well with alcohol first, then chlorhexadine or povidine-iodine (betadine) • Clean in a circular motion, allow to dry • ASSESS SITE • Apply transparent dressing, reinforce with tape, and LABEL. • Document

23. Documentation • Legal, ethical , and professional responsibility • Includes: • Insertion procedure • Proper infusion and maintenance • Monitoring of site and infusion • Direct care given (i.e. dressings, tubing changes, patient education, etc.)

24. Complications • Systemic - problem involving the entire body, related to IV therapy • Local - adverse reaction or trauma to the surrounding venipuncture site. • Hypersensitivity - can be systemic or local

25. Systemic Complications • Circulatory overload - usually infused toofast, or with hepatic, cardiac, renal disease • Dyspnea, cough, edema, wt. gain, rales or crackles • Decrease IV rate, elevate HOB, obtain vitals & assess the patient, notify physician • Infection (septicemia) - microorganisms in circulatory system • Fever, chills, tachycardia, tachypnea, headache • ? IV contaminated, break in aseptic technique • Notify physician, treat symptoms, blood cultures, remove IV • Establish another IV site

27. Systemic Complications • Venous Air Embolism - rare, but lethal • Air trapped in Rt. Ventricle lodges against pulmonary valve Blocks flow of blood to pulmonary artery Right heart overfills Small bubbles may enter pulmonary circulation • Tachycardia, SOB, shoulder pain, JVD, hypotension, weak pulse, lightheadedness • Immediately – pt. on left side, trendelenburg, notify physician • Causes air to rise in right atrium, prevents air from entering pulmonary artery • Obtain vitals and pulse oximetry, administer oxygen

28. Systemic Complications • Speed Shock - foreign substance (usually medication) is rapidly introduced into circulation • Usually results in hypertension • Slow infusion rate, notify physician • Vancomycin = “red man syndrome” • Incompatibility • Drug interactions • Allergic reaction

30. Local Complications *Common area for nursing malpractice • Phlebitis - Inflammation of the vein, common • Redness, pain, swelling, induration • *symptoms worse w/ thrombophlebitis = clot • Remove IV and relocate • Tx: Warm compresses • Prevention = rotate sites every 72 hours • ASSESS site hourly !

32. Local Complications • Infiltration - seeping of fluid into surrounding tissue • Site is cool with dependent edema, and often painful. • Tx: Discontinue IV solution, remove catheter, apply warm compresses, elevate extremity • Prevention = hourly IV site checks !

34. Local Complications • Infection - related to microbial contamination of the catheter or the infusate • Extravasation - infiltration of a vesicant medication, can cause blisters and subsequent sloughing of tissues • Chemo • IV potassium at higher concentration (over 40meq) • Dopamine • Dilantin • Flagyl

36. Local Complications • Hematoma – infiltration of blood into extravascular tissues • SQ hematoma is a localized collection of blood and is the most common local complication. • May see discoloration of skin • Usually related to nursing skills • Higher risk in pts. on anticoagulants • Higher risk in elderly

37. Preventing Complications • Use aseptic technique • HANDWASHING • Inspect all fluids & equipment before use • Be alert to signs of circulatory overload • JVD, elevated BP, elevated RR, moist crackles, edema weight gain • Anchor IV cannula well to prevent motion • Do not use veins over area of joint flexion

38. PN Scope of Practice • Must complete state approved infusion course • Must attend annual review (CEU’s) to maintain skills • May not administer meds which require titration (insulin, heparin, cardizem, etc.) • May not administer blood products • May administer saline flushes & heparin flushes • May administer TPN & lipids

39. PN Scope of Practice • Peripheral Line: may insert & D/C, flush, change tubing, site care • PICC Line: may not insert or D/C; ok to flush, change tubing, site care, draw blood • ?? Check hospital policy ! • Central Line: may not D/C; ok to flush, draw blood, change tubing and perform site care • ?? Check hospital policy ! • POC: may NOT flush or access, may not draw blood, may change tubing and administer IVPB • ?? Check hospital policy !

40. PN Scope of Practice • Guidelines are provided by State Board of Nursing • MUST always follow institution policy – this may vary from state guidelines

41. INS Standard • The nurse shall educate the patient, caregiver, or legally authorized representative: • Prescribed infusion therapy • Plan of care • Potential complications associated with therapy • Peripheral or Central • Risks • Benefits