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Vascular Access at MUSC

Vascular Access at MUSC. Lynn Williams, RN Vascular Access Resource Nurse Specialty Nursing Department. Vascular Access Devices 2013. Objectives: Intro to Infusion Nursing Society (INS) Identify common types of venous access devices, inc general characteristics

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Vascular Access at MUSC

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  1. Vascular Access at MUSC Lynn Williams, RN Vascular Access Resource Nurse Specialty Nursing Department

  2. Vascular Access Devices2013 Objectives: • Intro to Infusion Nursing Society (INS) • Identify common types of venous access devices, inc general characteristics • Discuss device selection & placement departments • Review assessment, care and management of central venous access devices – C75 Central Venous Catheter Policy • Identify potential complications and related interventions regarding a central venous access device

  3. Infusion Nursing Society(INS) • Recognized as the global authority in infusion nursing, dedicated to exceeding the public’s expectations of excellence by setting the standard for infusion care. • The Standards of Practice are written to be applicable in all patient settings & address all patient populations. • Be advised – the “Standards” is a legally recognized document.

  4. General Characteristics of CVAD Catheter Materials Polyurethane, Silicone, Impregnated, FDA approved for Power injection of IV contrast during radiological imaging French Sizes 1.2 fr – 15 fr Lumens Single, double, triple, & quad available *Golden rule – Less is more! Cuffed vs non-cuffed Valves Internal (tip) – Groshong External (hub) – PASV, Solo Power PICC 4

  5. Choosing the Best VAD for EachPatient Diagnosis Prescribed therapy Duration of therapy Physical assessment Patient health history Support system/resources Case Managers Patient preference 5

  6. List of drugs that d/t pH, osmolality or chemical structure, cause frequent IV restarts Amphotericin-irritant Bactrim - pH 10.0 Calcium Gluconate – Hypertonic Chemo Vesicants- pH Ciprofloxacin – pH 3.3 Dilantin – pH 12.0 Dobutamine – pH 2.5 Erthromycin – irritant Morphine(PCA) – pH 2.5 All Penicillins – pH 10/hypertonic Phenergan – pH 4.0 Potassium >20 KCL – Hypertonic PPN/TPN – Hypertonic Rocephin – Irritant/hypertonic Tobramycin – pH 3.0 Vancomycin – pH 2.4

  7. Selection of Catheters and Sites

  8. CDC RecommendationsCatheters & Site selection • PIV vs PICC: Use a peripherally inserted central catheter (PICC) when the duration of IV Therapy will likely exceed six days • Weigh the risks/benefits of placing a central venous device (CVD) at a recommended site to reduce infectious vs mechanical complications (IJ vs Subcl vs femoral)

  9. Catheter & Site Selection cont’d • Choose a device with the minimum # of lumens/chambers essential for treatment • Promptly remove catheters that are no longer essential

  10. Central Venous Access Devices • Peripherally Inserted Central Catheters (PICC) • Regular & cuffed/tunneled • Non-tunneled/Non-cuffed Central Catheters • Tunneled/Cuffed Central Catheters • Implanted Ports – regular vs power 10

  11. Departments that Place &/or Manage CVAD’s • VAIN Team • Bedside PICC & difficult PIV insertion • Screen all Adult IP PICC orders • Adults • Interventional Radiology Dept. • Place all types of venous access devices • All ages • Infectious Disease PICC Service • Place both cuffed & regular PICCs • Bronch Lab, EP, Cath Lab • Adults • OR/Surgeons • All ages • All devices EXCEPT PICCs • Pediatric Services • Procedural area on 5th floor of CH – PICCs • Bedside PICCs by specialized RNs in ICUs

  12. Peripherally Inserted Central CathetersPICCs • Usually inserted using a vein in upper arm • Can be used for most IV therapies and to obtain blood draws • Select for pt’s requiring IV abx’s, TPN, poor IV access needing frequent blood draws • Easily removed either at bedside while an IP or by a Home Health Nurse after discharge • FYI – if pt has no insurance, they are unable to have device cared for at home

  13. Adult PICC White Board • All Adult PICC orders go to the VAIN team for evaluation and dept assignment for device insertion • White Board provides info r/t which dept is assigned to insert PICC w/ comments • Certain criteria dictate which dept is best suited to place the PICC: occlusion history, sedation, complicated diagnosis

  14. Found on the Intranet

  15. PICCs Placed at MUSC BARD Power PICC (polyurethane) Cook Silastic PICCs Cook Spectrum (polyurethane, Abx impregnated)

  16. Non-Tunneled CVC (no cuff) Short term, Acute care, percutaneous catheters Typically used for days – weeks for all types of IV therapy, blood draws, monitor central venous pressure in ICUs Example: PICCs, Acute single/dual/triple/Quad CVCs, Dialysis/aPheresis catheters Tunneled CVC (cuffed) Long term therapies – TPN, chemo Oncology, Cardiac, GI patients Dacron cuff provides catheter stability and serves as a barrier to prevent infection Examples: Cuffed PICCs, Chronic Dialysis/aPheresis catheters, Hickman, Broviac, Centrally Inserted Catheter 18

  17. Tunneled Non-tunneled IJ entry site IJ entry site Subcutaneous Tunnel w/ cuff No subcutaneous Tunnel or cuff

  18. Implantable Ports

  19. ImplantablePorts Implanted Ports - Plastic, stainless steel or titanium housing attached to a catheter implanted under the skin Chest, Arm, Thigh, Abdomen Completely under skin – swimming permitted when not accessed once the incision has totally healed Requires special non-coring needles to access Available as power injectable Can remain in place for years Sickle cell, Oncology, Rheumatoid Arthritis, intermittent long term tx’s 21

  20. Identifying Power Ports • Prior to a fluoroscopic exam requiring power injection of contrast: • Clinical staff (radiology techs, RNs) will positively ID device • Manufacturers ID card, arm bracelet, key tag • Manufacturers sticker found on IR/OR document • Image – view “CT” marker on port chamber • Radiologist to review prior image before being used • If no prior image, an image of the appropriate anatomic area will be done & reviewed by Radiologist • Radiology Dept. has a process they follow to confirm if a device is power injectable.

  21. Port Needle Sets

  22. BeforeMeds can be administered via CVAD: Verify tip location using fluoroscopy For newly placed devices Transferred patients with an indwelling central venous catheter If there is a known or questionable change in catheter position Migration or dislodgement suspected Securement device has become dislodged S/S: No blood return &/or unable to flush If no blood return, device is not to be used until evaluated/treated for clot/thrombus or mechanical issues!

  23. IV Flush Orders • Practitioner must write order for heparin flushes • Standard Adult and Pediatric flush orders • Eachdevice has a standard flushing protocol including 0.9% sodium chloride and heparin • If heparin is contraindicated, consider alternative, such as argatroban or tPA • When patient is admitted with a device, initiate the order for RN to get heparin

  24. Dialysis/aPheresis catheters • Locked with high-dose heparin • Refer to IV Flush Orders • Adults: Use 1000u/ml heparin • Pediatrics: Use 100u/ml heparin • May only be accessed by nurses trained to do so (ICU, aPheresis & Dialysis RNs) • Renal service must be consulted before using catheter. If no longer being used for aPheresis &/or dialysis, the Renal MD MUST transfer care to RNs on unit.

  25. Post-Insertion Complications Catheter Dislodgement Catheter Migration Air Embolism Catheter-related Bloodstream Infection Venous Thrombosis Catheter Occlusion 28

  26. Catheter Dislodgement • Stabilization devices (Statlock, sutures, securement dressings) are used to prevent catheter from falling out, catheter tip malposition, and migration of bacteria • If displacement is suspected, CXR is required to verify tip placement • S/S of dislodgement – catheter malfunctioning, securement device lose, device is semi-pulled out • Do not try to re-insert the device 29

  27. Catheter Migration • Tip can spontaneously migrate into right atrium or internal jugular • May result from coughing, ventilator, forceful flushing, heavy lifting, hypertension • S/S = Inability to flush, infuse or aspirate • “Ear gurgling” or “running stream” while catheter is being flushed • Get a chest x-ray 30

  28. Catheter Tip Malposition Catheter tip right jugular

  29. Catheter Related Bloodstream Infections (CRBSI) During CVC insertion – use maximal sterile barrier precautions: Cap, mask, sterile gown, sterile gloves, sterile full body drape Put mask on if removing a dressing to inspect a site Prep skin using Chlorhexidine gluconate w/ alcohol – allow to dry!! Assess catheter necessity daily!

  30. Venous Thrombosis • Diagnosed via Vascular Ultrasound • What do you do?? • Before removal, consider this: • Is the catheter functioning normally? • Are symptoms manageable? • Can patient receive anticoagulant treatment? • Does patient have known occluded vessels that will compromise a new device plcmt in the future? • Consider patients condition, long term treatment and the need for the existing device

  31. Occlusion Management • Partial Occlusion: device flushes, no blood return • Total Occlusion: No flush or aspiration via device • Both types of occlusions can safely be treated with Cathflo Activase (alteplase) • If mechanical malfunction has been ruled out, order Cathflo for catheter occlusion • Follow Occlusion Management guidelines (Appendix B in C75 Policy)

  32. Device Removal • RNs have to demonstrate competency to remove a non-tunneled catheter. • RN competency is based on skill & frequency of performance • ONLY dialysis or ICU RNs w/ demonstrated competency may remove large bore catheters (dialysis/aphersis) • ONLY MDs and non-surgical specialist that are credentialed may remove cuffed devices, including PICCs.

  33. Air embolism = entry of a bolus of air into the vascular system; can occur during placement or after device removal Reduce the risk of embolism: • Place the patient in Trendelenberg position to increase intrathoracic pressure, unless not tolerated or contraindicated • Have patient hold breath and gently bear down (Valsalva). • Sx’s & Sx’s include: palpitations, resp distress, hypotension, arrhythmias,

  34. Non healing site over port!

  35. Post port plcmt – bruising!

  36. Extravasation

  37. CDC Recommendations Educate/training clinicians who insert/maintain cath’s – *SIM Lab program being developed Use maximal sterile barrier precautions Use >0.5% chlorhexidine skin prep w/ alcohol (ChloraPrep = 2% = isopropyl alcohol) Avoid routine replcmt of CVCs as strategy to prevent infection Periodically assess knowledge of & adherence to guidelines

  38. Central Venous Catheter Policy • Owner: Central Venous Access Committee • Multidisciplinary team • Purpose: Provide guidelines for the insertion & care of all VADs • For all staff that handle or insert a Central VAD • Includes: • 8 Appendix Included: References, VAD Occlusion Mgmt, IV Flush Orders (Peds/Adults), CVL Guideline, Ethanol Lock Info Sheet, VAIN Team Guidelines

  39. Questions??? Lynn Williams, RN Vascular Access Resource Nurse 792-1143 11109

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