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 components2. 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 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.

Known Complications of IV Therapy

PhlebitisContributing 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

InfectionContributing factors:• Contaminated infusions• Inadequate skin preparation• Poor technique• Host factors

Extravasation

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

Selection of EquipmentCannula 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

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

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 avoidveins 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

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

Patient’s condition Anticipated length of therapy

Types Of Central Venous Catheters

Nontunneled central catheters Tunneled central catheters Peripherally inserted central catheters

(PICC) Implantable ports

NON-TUNNELED EXTERNAL CATHETERS1. 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

Used for short-term therapy Inserted percutaneously

Subclavian vein Internal jugular veinFemoral vein

Has from 1 to 4 lumens or ports Usually from 6 to 8 inches in length

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

1. Single or multiple lumens

2. Flow - variable

3. Long term

4. Easy access (no skin puncture)

5. Cuff - Dacron, vita

Tunneled catheter with cuffs

Tunneled catheter

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)

Used for intermediate to long term therapy May be single or double lumen Inserted percutaneously

Basalic veinCephalic vein

Threaded into the superior vena cava May be inserted by specially trained RN

PICC LINES

1. Silastic or polyurethane

2. Single or double lumen

3. Low flow

4. Short - long term

5. Easy access

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 PORTS1. Single or double lumen

2. Flow - most commonly slow

3. Long term

4. Access requires needle puncture

5. Less maintenance

6. Activity is unlimited after site heals

7. Cosmetically more appealing

8. Concealed pocket retards infection (?)

SUBCUTANEOUS PORTS

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

STENOSIS THROMBOSI PINCH OFF

SYNDROME

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

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

1. Prep

2. Access

3. +/- Tunnel

4. Secure

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

PREP

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

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

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

Flushing of linesEach lumen is treated as a separate cath Injection caps are vigorously cleaned with

alcoholUse 10cc or larger syringe for administration

of meds or flush Turbulent flush technique is recommended

For med administration, use SAS methodIf port is not to be maintained with a

continuous infusion, end with Heparin flush solutionPeds 10kg> and adults – 100 units

Heparin/ml with preservativesNeonates and peds <10kg – 10 units

Heparin/ml without preservativesFor specific amounts see procedure

Clamp cath while infusing last ½ cc of flushIf CLC 2000 used, do not clamp cath until

syringe disconnected

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

Dressing changes per protocolUse sterile techniqueChange when damp, soiled or loosenedChange every 7 days if transparentChange every other day if gauze is usedClean skin around insertion site with

alcohol in a circular motion. Also clean cath with alcohol

Use antmicrobial disk if indicatedForm a loop of the tubing or cath outside

the dressing and anchor securely with tapeLabel site with date, time and initialsDocument dressing change, condition of

site and length of external cath when appropriate

For drawing blood specimenDiscard initial sample of bloodCollect specimenFlush with 10cc salineFlush with Heparin solution if

indicated

Monitor for complicationsInfection

PhlebitisSepticemia or pyrogenic reaction

Air embolismThrombosis/occlusionExtravasationDamaged cath

COMPLICATIONS

1. Acute Procedural

2. Sub-acute Infection

3. Chronic

Infection

Catheter fragmentation

Non-function

COMPLICATIONS:ACUTE1. Spasm 4. Pneumothorax

2. Access failure 5. Malposition

3. Arterial puncture 6. Air embolus

AIR EMBOLUS: SYMPTOMS

1. Respiratory distress

2. Increased heart rate

3. pulse

5. Cyanosis

4. Poore in the level of consciousness

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

1. Infection

2. Catheter fragmentation

3. Non-function

Risk Factors

Four major risk factors are associated with increased catheter-related infection rates:Cutaneous colonization of the

insertion siteMoisture under the dressingProlonged catheter timeTechnique of care and placement of

the central line

Evidence-Based Strategies Selected to Reduce CLA-BSIs

1. Central line-associated bloodstream infections bundle

2. Hand hygiene

3. Maximal sterile barriers

4. Chlorhexidine for skin asepsis

5. Avoid femoral lines

6. Avoid/remove unnecessary lines

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 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

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

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

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

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

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 Once placed, there should be periodic, if

not daily assessment, of its continued need, with emphasis on prompt removal

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

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

Staph epidermidis 25-50%

Staph aureus 25%

Candida 5-10%

INFECTION

1. Septic thrombophlebitis - remove catheter

2. Cutaneous - local treatment3. Bacteremia -

1. IV antibiotics 48 -72 hoursif improved - keep catheterif no change, worse or recursremove catheter or2. Exchange catheter over wire, 85% cure with treatment

Continue to treat infection for 10 - 14 days

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

INFECTION

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

When to call the physicianTemp of 100.5F or greaterChills, dyspnea, dizzinessPain, redness, swelling, or drainage at

siteUnresolved resistance, pain or fluid

leaking while flushingHole or tear in cathExcessive bleeding at siteChange in length of external cathSwelling in neck, face, chest, or arm

General safety measuresNo sharp objects near cath Clamp cath when not in useNo pulling or tension on the cathDiscard syringes and needles in sharps

containerActivity limitationsUse a stress loop

Home health referral

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