IV TERAPY & Central Venous Catheters

1. IV TERAPY &Central Venous Catheters

2. 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

3. 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.

4. Known Complications of IV Therapy

5. 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

6. Infection Contributing factors: • Contaminated infusions • Inadequate skin preparation • Poor technique • Host factors

7. Extravasation Contributing factors • Age • Site of cannula • Type of cannula • Duration of cannula • IV drug infusions

8. 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.

9. Skin prep Antiseptic solution - 70% isopropyl alcohol, 0.5 - 1% Chlorhexidine. Use an aqueous based alternative if there is a known allergy to alcohol

10. 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)

11. 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

12. Type of CVC Inserted Depends On • Patient’s condition • Anticipated length of therapy

13. Types Of Central Venous Catheters • Nontunneled central catheters • Tunneled central catheters • Peripherally inserted central catheters (PICC) • Implantable ports

14. 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

16. 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

17. 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

18. TUNNELED CATHETERS 1. Single or multiple lumens 2. Flow - variable 3. Long term 4. Easy access (no skin puncture) 5. Cuff - Dacron, vita

19. Tunneled catheter with cuffs

20. Tunneled catheter

21. 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

24. 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

25. PICC LINES 1. Silastic or polyurethane 2. Single or double lumen 3. Low flow 4. Short - long term 5. Easy access

27. 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

28. SUBCUTANEOUS PORTS 1. Single or double lumen 2. Flow - most commonly slow 3. Long term 4. Access requires needle puncture

29. SUBCUTANEOUS PORTS 5. Less maintenance 6. Activity is unlimited after site heals 7. Cosmetically more appealing 8. Concealed pocket retards infection (?)

30. 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

33. SUBCLAVIAN VEIN COMPLICATIONS STENOSIS THROMBOSI PINCH OFF SYNDROME Subclavian vein (SCV) access is prone to more complications than internal jugular vein (IJV)

34. 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

35. CENTRAL VENOUS CATHETER PLACEMENT 1. Prep 2. Access 3. +/- Tunnel 4. Secure

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. For drawing blood specimen • Discard initial sample of blood • Collect specimen • Flush with 10cc saline • Flush with Heparin solution if indicated

46. Monitor for complications • Infection • Phlebitis • Septicemia or pyrogenic reaction • Air embolism • Thrombosis/occlusion • Extravasation • Damaged cath

47. COMPLICATIONS 1. Acute Procedural 2. Sub-acute Infection 3. Chronic Infection Catheter fragmentation Non-function

48. COMPLICATIONS:ACUTE 1. Spasm 4. Pneumothorax 2. Access failure 5. Malposition 3. Arterial puncture 6. Air embolus

49. AIR EMBOLUS: SYMPTOMS 1. Respiratory distress 2. Increased heart rate 3. pulse 5. Cyanosis 4. Poore in the level of consciousness

50. 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