Central Venous Catheters

1. Central Venous Catheters

2. Why is this so important? The CDC estimates that there are 250,000 central line associated bloodstream infections (CLABSIs) every year. �Central line associated bloodstream infections kill over 30,000 people per year in the U.S. �Protecting patients from harm, including morbidity and mortality that come from central line associated bloodstream infections, is our duty. The AIM FOR ZERO campaign initiative is to have Zero Infection, Zero Harm and Zero Waste

3. Central Venous Catheter: What is it? A central venous catheter (CVC) is a sterile catheter that is inserted through a large vein, such as the subclavian, jugular, or brachial veins. Optimal tip termination of a CVC is the superior vena cava (SVC) or the Cavoatrial Junction (CAJ) . It can be used to administer medication or fluids, obtain blood tests and directly obtain cardiovascular measurements such as the central venous pressure. The following are generally considered CVC lines (Review catheter position notation for termination in SVC/CAJ and appropriate usage) : Subclavian Internal Jugular (IJ) PICC Dialysis catheter Femoral

4. Indicators for a Central Venous Catheter (CVC) include: Intravenous medication is a vessicant and requires hemodilution in a large central vein (e.g. vasoactive medications, extreme pH or osmolarity) Temporary hemodialysis access Hemodynamic instability/need for monitoring to guide treatment Total parenteral nutrition containing more than 10% dextrose or 5% protein High volume fluid infusions for resuscitation Infusion of multiple blood products Transvenous pacemakers Long term venous access/lack of sustainable peripheral access

5. CVC � Identification A subclavian or IJ central venous catheter is a catheter that is placed into a large vein in the neck (internal jugular vein) or chest (subclavian vein) It is used to administer medication or fluids, obtain blood tests and directly obtain cardiovascular measurements such as the central venous pressure. Some subclavian or IJ central catheters can be used for power injection, meaning they can be utilized for power CT injection. They can be easily identified by their manufacturing labels (IFU indications for usage). Generally sutured in place. Often inserted for urgent venous access and considered a short-term CVC.

6. CVC � Identification A PICC is inserted in a peripheral vein, such as the cephalic vein, basilic vein, or brachial vein and then advanced through increasingly larger veins, toward the heart until the tip rests in the SVC or cavoatrial junction. Some PICC catheters can be used for power injection, meaning they can be utilized for power CT injection. They can be easily identified by their manufacturing labels (IFU indications for usage). Used frequently for patients needing home therapy. Generally not sutured in place, but secured with stabilization device. Can be inserted at the bedside.

7. CVC � Identification Hemodialysis Catheter A hemodialysis catheter is a catheter used for exchanging blood to and from the hemodialysis machine from the patient. These double-lumen catheters are considered temporary dialysis accesses. The internal jugular site is preferable to the subclavian site in patients who do or will have permanent dialysis accesses placed in their arms. The catheters have two ports � one colored red and one colored blue. The red port is used for withdrawing the patient's blood and sending it to the dialyzer, and the blue port is used for returning the dialyzed blood to the patient. Do not inject IV fluids or medications into either port of the double-lumen catheter. This central venous access device is used for hemodialysis only.

8. CVC � Identification Tunneled Central Venous Catheter A tunneled CVC is placed using a subcutaneous tunnel to separate the vein entry site from the skin exit site. There are 2 sites during insertion- The first, being the catheter tunneling site on the chest wall. The second, being the venipuncture entrance site that is located near the subclavian vein or IJ vein. A tunneled CVC is generally cuffed. Common types of Tunneled CVCs are: Hickman Broviac Hickman lines are considered an extended venous access device. A physician or LIP is required for the removal of a Hickman (due to this being a tunneled catheter.)

9. CVC � Identification Implanted or Injection Ports A port (e.g. Port-A-Cath) is a small medical device which is placed under the surface of the skin, inside a surgically created pocket. A catheter connects the port to a vein. Under the skin, the port has a septum through which drugs can be injected and blood samples can be drawn. The surgical port placement pocket is usually created in the upper chest but, may also be placed in the upper part of the arm. These devices may be single or double septum and lumen. An implanted port is considered an extended dwell catheter. Some implanted ports can be used for power injection, meaning they can be utilized for power CT injection. See manufacturing labels for IFU. Because the device is completely covered by the patient�s skin, the risk for CRBSI is reduced. To access the port, a special non-coring needle (Huber) is inserted perpendicular to the reservoir. The septum is designed to withstand hundreds of punctures.

10. CVC � Identification A femoral central venous catheter is inserted utilizing the femoral vein in the groin. It is generally inserted as a last resort for emergent venous access. Some indications for inserting a CVC utilizing the femoral route include: Emergency catheterization Severe hypoxemia Anatomic- Unable to access Basilic vein, Brachial vein, Cephalic vein, Internal Jugular, or Subclavian Blood coagulation disorder Platelet <50,000 or PT >1.5 INR or PTT>2X normal PaO2/FiO2 <150 mm Hg Temporary Dialysis Catheter Access

11. CVC Insertion Assist CVC Insertion Assist Verify informed consent is signed and completed. Complete Procedural Time Out Insure the Physician/proceduralist and/ or Team members have performed hand hygiene. Gather supplies. Surgical Asepsis Don a mask, cap and clean gloves Insure Physician/proceduralist Don mask, face shield, cap, sterile gloves and gown- Monitor for breaches in procedure sterility. Insure patient is covered with full body drape. Assist proceduralist as needed during CVC insertion Insure all ports are flushed post procedure and if CVC has clamp(s) they shall be locked

12. Post CVC Insertion Documentation and Care Post CVC Insertion Assist patient to a comfortable position. Educate patient and/or family on CVC Document insertion of CVC in Meditech via the [CVC/PICC Line Insertion] intervention. Assure that CXR is performed Obtain verification for CVC usage from Physician/proceduralist.

13. Post CVC placementAssessment and Monitoring  Assess and monitor patient for any post procedural complications: Dyspnea Tachycardia Unequal breath sounds Chest pain Bleeding Pneumothorax Air embolism Catheter malposition Presence of subcutaneous emphysema

14. Routine/Daily IV Site Care Requirements for All IV sites including PICC and all Central Lines: All sites must be dated with the date the dressing was applied. All sites MUST have an intact dressing with no peeling or loose edges. NEVER reinforce a loose or compromised dressing with tape. Change it! Central line dressings must be changed every seven days and/or PRN. See facility policies and procedures for use of antimicrobial dressing/patch. Full assessment on all CVC line(s) MUST be completed and documented in Meditech each shift. Assess patient every shift for: Signs and symptoms of possible bloodstream infection. Continued need of central venous access device. Lines not needed should be discontinued. Document daily need for CVC in Meditech.

15. Routine IV tubing & End Cap Care IV tubing shall be changed- After blood administration. With all new CVC line insertions. Every twenty four hours when a patient is on TPN and lipids. Per facility protocol Catheter end caps shall be changed- With each dressing change. After blood infusion. Prior to obtaining blood culture sample. With all IV tubing changes. Per facility protocol

16. CVC � Dressing Change Gather appropriate equipment for CVC Dressing change per facility protocol. Perform hand hygiene and don clean gloves. Remove old dressing and discard appropriately. Remove gloves; Perform hand hygiene. Open Central Line Dressing Kit and establish sterile field 6. Don Mask, Don sterile gloves. Use a 2% Chlorahexadine antiseptic to cleanse the area. Allow area to dry, do not fan. If catheter securement is utilized, follow procedure for device application. Apply antimicrobial disc or dressing per facility protocol. 11. Apply semi-permeable transparent dressing. Insure catheter extension(s) are secure. Label CVC dressing per facility protocol Change injection cap(s) using aseptic technique..

17. Insert a new empty 10mL syringe into needleless end-cap and carefully obtain blood sample. Immediately after blood specimen is obtained, flush CVC with 20mL NS and transfer blood specimen via a needleless connector to the appropriate tube. (Check facility policy and procedure) For facilities that utilize a Heparin Lock Flush; If there are no continuous infusion. Flush CVC with 3mL of Heparin(100 units/mL) and apply clamp (Check facility policy and procedure) Clamp shall be applied for CVC devices that are not infusing medication (Check facility policy and procedure) Dispose of used supplies appropriately, remove gloves and perform hand hygiene. Restart fluids per physician order if CVC not clamped. Apply appropriate patient identification label at patient location and send laboratory specimens for analysis. Document in Meditech CVC � Blood Sampling Prior to collecting blood from CVC check facility policy and procedure for guidelines with CVC blood sampling. The distal lumen is generally the preferred lumen from which to obtain a blood specimen (Please catheter manufactures IFU). Gather appropriate equipment for CVC Blood Sampling per facility protocol. Perform hand hygiene and don clean gloves. Discontinue all Infusions into the CVC before obtaining blood sample. Scrub the hub with Isopropyl Alcohol wipe for 10-15 seconds and allow it to dry. Note some facilities require changing the end-cap prior to obtaining a blood culture sample. (Check facility policy and procedure). Check CVC for patency by flushing CVC with preservative free 0.9% sodium chloride/Normal Saline (NS) utilizing a 10mL syringe (Check facility policy and procedure). With an empty syringe carefully withdraw 5mL of blood from CVC and discard in appropriately (Check facility policy and procedure).

18. The Do's and Don'ts of Central Line (CVC) Care

19. The Do's and Don'ts of Central Line (CVC) Care

20. Considerations for CVC Removal Considered aseptic or sterile procedure. Patient shall be in slight trendelenburg position, as tolerated. Ask patient to perform the Valsalva maneuver and/or hold breath during catheter removal to prevent formation of an air embolism. Remove the catheter by grasping it with the dominant hand and withdrawing in one continuous motion. Inspect and note CVC for length. The removal length shall be equal to the insertion length. After removal apply pressure dressing to puncture site for at least 5 minutes. Apply sterile semi-permeable transparent dressing and/or antimicrobial ointment per facility protocol. Document removal of central access device in �CVC/PICC Daily Care and Removal� Intervention in Meditech.

21. CVC � Troubleshooting Line Patency Problem Solving Steps Assess the line for possible mechanical obstruction (occlusions, kinks, closed clamps, etc). Reposition the patient (sit-up, lay back, raise upper extremity, etc). Leaking around a CVC site may indicate the presence of a DVT, contact physician. If the line continues to remain non-patent, sluggish or without blood return, suspect a line occlusion. Contact the physician for catheter clearance. CAUTION CONSULT FACILITY POLICY AND PROCEDURE FOR CATHER CLEARENCE ADMINISTRATION PRIVILAGES

22. Patient Education Provide Education to Decrease the Risk for Central Line Infection Frequent hand washing. Limit touching line(s) and catheter site. Prevent rubbing or pulling on the catheter. Prevent catheter from getting wet. Notify Physician if sutures become loose, catheter has significant movement or has become dislodged. Provide Education Regarding Signs & Symptoms of Infection Fever over 101? F. Bleeding or oozing around the catheter site. Redness or tenderness at site. Arm becomes swollen (PICC).

23. Sources for this Presentation: Centerpoint Medical Center. (2010). Central Venous Catheters.,Independence, MO. Emory Eastside Medical Center. (2010). Aim for Zero presentation, Snellville,�GA. HCA Atlas. (2010). Aim for Zero toolkit Infusion Nurses Society (2006). Infusion Nursing Standards of Practice. Infusion Nurses Society (2010). Infusion Nursing An Evidence-Based Approach (3rd ed.) Infusion Nurses Society (2006). Policies and Procedures for Infusion Nursing (3rd ed.)

24. This concludes the Central