central lines

peripheral venous access devices (PVAD) vs central venous access devices (CVAD)

1. PVAD

• midline catheters

• peripheral IV catheters (14-26G)

• not ideal for vesicant meds or parenteral nutrition formulas

• short term, dilute solutions

2. CVAD

• IV catheter inserted into a superficial or deep central vein

• typically terminates in the superior vena cava

• ideal for vesicants & parenteral nutrition formulas

• sterile insertion by HCP or specially trained nurse

• long term, concentrated, irritating, or high volume therapy

what is a central line? what does selection of CVC focus on?

• IV catheter placed at a large central vein (usually the subclavian, jugular, superior vena cava)

• focuses on the length of need of IV access & types of meds planned for infusion (uses an algorithm to decide access)

4 types of central venous catheters (CVC), which ones are short vs long term

1. percutaneous (non-tunneled)

• acute, short term

2. peripherally inserted central catheter (PICC)

• long catheter, long term use

3. tunneled

• chronic, long term

4. implanted ports

5. short term: percutaneous, PICC

6. long term: tunneled, implanted ports

CVC purposes

• to deliver large volumes rapidly (fluid of blood)

• to deliver hyperosmolar or vesicant solutions (ex. K+, chemotherapy)

• multiple IV infusions or meds

• TPN

• measure CVP (2-6 mmHg; 2.5-12 H2O)

• long term fluids, antibiotics

• when peripheral access is not possible

what vein to avoid for centrally inserted catheter? how to confirm placement? what is multilumen indicated for? which long term CVC is preferred over the other?

• avoid femoral vein → fecal & urine contamination

• confirm placement by chest xray

• multilumen indicated for critically ill

• tunneled preferred over implanted port b/c lower risk

what is percutaneous (non-tunneled → what does this mean) central line? how long is placement duration? what are the uses & risks? what to do before using the line?

• inserted directly through the skin into a central vein (subclavian, jugular, femoral) inserted by bedside & sutured

• placement time is limited to 7 days

• multiple lumens available, daily heparin flushes

• uses: emergency access, ICU pts, short term, TPN, vasopressors

• risk: highest infection rate of all CVCs, accidental dislodgment, pneumothorax

• confirm placement with xray before use

percutaneous central line nursing considerations (when to change dressing, tubing, gauze, how to remove)

• sterile transparent dressing

  • change when damp or loose → to prevent infections

  • every 3-7 days

  • per agency protocols

• gauze dressing every 48 hrs

• tubing change every 72 hrs, after blood/lipids → per agency

• easy to remove (can be taken out at beside)

  • place pt is trendelenburg position

  • exhale as catheter removed (minimizes air embolism)

  • apply pressure over site 2 mins until hemostasis

what is tunneled catheter? how long is the placement duration? how is it inserted? what is the use & risks? is this a lower infection risk & to what?

• catheter tunneled under the skin (subcutaneous tissue) before entering central vein (subclavian) & catheter tip advanced into superior vena cava

• has a dacron cuff in tissue to reduce infection risk & inhibits organism migration

• duration: long term placement (months to years)

• inserted in surgery or interventional radiology

• has a lower rate of CLABSI (central line associated bloodstream infection) vs non-tunneled

• uses: long term, TPN, dialysis, frequent blood draws, chemo

• risk: surgical insertion required, but lower infection risk than percutaneous

what is the purpose of the dacron cuff in tunneled central line? why do tunneled lines do not need dressing? when do we need a dressing?

• purpose: reduce infection risk by filtering bacteria from entering

• do not need dressing after scar forms & heals in 7-10 days unless high risk for infection & misplacement

• use dressing to protect catheter until scar tissue forms

what is peripherally inserted central catheter (PICC)? how is it inserted? duration of placement? does this have low infection rates? uses/tx & risks? what to avoid on the arm with PICC?

• inserted into a peripheral vein (basilic, cephalic, brachial) & advanced to superior vena cava

• inserted @ bedside by physician/trained RN

• duration: weeks to months (6 mons)

• yes low infection rates w/ proper protocol care

• uses: long term antibiotics, chemotherapy w/ vesicants, meds w/ high osmolarity

• risks: thrombosis, line occlusion, infection

• avoid taking BP/venipuncture in the same arm

PICC nursing considerations (when to change dressing, tubing, biopatch, what does this require when capped)

• measure & document external length of catheter (check inward migration & for removal)

• dressing anchors & seals

• biopatch inhibits bacteria (if it looks fine, ok to keep for 7 days)

• sterile dressing change:

  • 24 hrs (if blood & no biopatch)

  • Q7 days or when damp, loose

• tubing change Q72 hrs, after blood/lipids

• requires heparin flush when capped

all central lines we need to do what before using?

confirm placement with xray before use

when do we not flush with heparin & what do we flush with?

groshong valve flush with normal saline ONLY

what is an implanted infusion port & how is it accessed? duration of placement?

• entire device implanted under skin & accessed with special non-coring Huber needle

  • upper chest or arm

• catheter attached to port or reservoir placed under the skin

• port is self healing (silicone) → seals back up when not accessing

  • required non-coring needle to access

    • allows 2000 punctures

    • puncture once per hospitalization

• duration: long term (months to years)

• medication slowly released from reservoir to blood stream

• advantages

  • cosmetic (can go swimming), maintenance

• accessing ports increases risk for infiltration/infection

what is required when port is accessed w/ needle? when it is not accessed? what type of needle is always used for the port & why? what do we flush with?

• accessed → sterile dressing required

• not accessed → no dressing needed

• huber needle to prevent septum damage

• flush with heparin or saline depending on protocol

implanted ports advantages vs disadvantages

1. advantages

• lowest risk for CLABSI → b/c port is internal

• low profile, improved self image

• minimal care (no dressing, infrequent flushing)

• easy access for large volumes, blood draw, vesicants

2. disadvantages

• cost of insertion

• postoperative care 7-10 days

• repeated needle sticks cause discomfort

• minor surgery to remove device

what type of procedure is central line insertion? what are these principles (summarize)?

• very strict sterile procedure

  • all items within sterile field must be sterile

  • sterile drapes are used to create sterile field

  • all items introduced into sterile field must be sterile

  • all personnel moving around the sterile field must do so while maintaining sterility

  • never turn backs on the sterile field

  • hands below the waist are outside the sterile field (hands always above waist)

what if steps are skipped in central line insertion checklist, what to do?

ANY provider can stop procedure

what syringe size do we use to flush CVCs & why?

• always 10 mL or larger for flushing

• smaller syringe + same force → higher pressure (higher PSI)

what method do we use to flush & why? why do we never force flush?

• slow & controlled flush

• use push-pause method to flush → cleans the line & positive pressure keeps it open

• want to keep pressure on plunger until clamped to prevent backflow of blood

• forcing flush could …

  • damage catheter, dislodge clot, irritate vessel/heart

if CVC is capped, what method do we use to flush?

• aspirate (discard aspirated blood IF the line is heparinized)

• saline

• administer med

• saline

• heparin → to prevent clots

does heparin concentration & volume differ per agency? how can we differentiate heparin syringes from normal saline flushes? what should we always check & why?

• yes

  • 10-100 units heparin per mL

  • 3-5 mLs per flush

• pre-filled heparin is color coded

• always check volume (mL) & concentration (units/mL)

  • 10 mL syringes → they are labeled 10 units per mL, 100 units per mL

  • large barrel syringes equivalent to 10 mL syringe but filled with 3 or 5 mL

what are power PICC lines (what is it designed for)? what does this not require us to do? what is it excellent for?

• power PICC lines (purple)

• designed to withstand 5 mL/1 second (300 psi)

• do not require push pause method when flushing or injecting

• ensures that the lumen you are using is indeed a power picc (purple line

• excellent for CT contrast (dye) injection

what amount should we always flush with & why? what is the goal? how much of the priming volume do we flush with?

• always flush with the smallest recommended volume b/c too much flush risk for fluid imbalance, too little flush risk for occlusion

• goal is just enough to keep the line patent & safe

• 2x the priming volume for flush

what is a Groshong valve, what type of catheter is it? what method do we use while flushing?

• tunneled catheter

• the valve at the tip prevents prevents air embolism & blood reflux

• flush with NS only

• use push-pause technique to maintain patency

how much normal saline do we flush Groshong with? when do we flush? why don’t we clamp?

• 6 mL NS

• we can flush before & after use or once weekly if catheter not in use

• clamping will damage the inherent valve system & everything can back flow

  • prevents air embolism & blood reflux

why do we need to do an xray for CVCs? where should the distal tip of the catheter be?

• to confirm placement & identify complications (hemothorax, pneumothorax, vessel puncture)

• distal tip should be just outside right atrium

  • if inside right atrium → may perforate myocardium & cause dysrhythmias

  • allows measurement of CVP

what does it mean if there are PVCs during CVC insertion?

catheter is too deep & causing ventricular irritation

how many lumens can be on a CVC?

single, double, triple, quadruple

what is the proximal, middle, distal port for? how has best practice updated?

• proximal (18G) → CVP measurement, lab draws, meds, blood products (everything else)

• middle (18G) → TPN (dedicated, undisturbed for infection control)

• distal (16G) → CVP measurement, blood products, high volume or viscous fluids, meds (BIGGEST & FASTEST)

• best practice update: any port may be used for lab draws as all infusing solutions are temporarily stopped thereby ensuring no lab specimen contamination

what are the complications of CVC?

• pneumothorax (lung puncture & letting air in)

• catheter migration

• catheter occlusion

• embolism, DVT (clot in the line)

• infection

  • insertion site (local or systemic)

  • CLABSI → life threatening sepsis

what is sepsis & what is it triggered by? what can it progress to? what are the early & progressive signs? how can we save lives (prevent worsening)?

• life threatening dysregulated response to infection that causes organ dysfunction → inflammatory response in overdrive & damaging own tissues & organs (infection, systemic inflammation, organ dysfunction)

• triggered by infection (bacteria, virus, fungi) → often pneumonia, UTI, blood stream infection

• can progress to septic shock → severe hypotension, poor perfusion, high risk of death

• early signs: fever OR hypothermia, tachycardia, tachypnea, confusion

• progression: hypotension, low urine output, lactic acidosis, organ failure

• save lives by early recognition, rapid tx (blood cultures, antibiotics, fluids)

what are the routes of CVC contamination? (most common, rarely) what should we do to prevent? where do early infections occur? later infections?

• most common: migration skin organisms at insertion site into skin & along catheter with colonization of the catheter tip

• catheter “seeded” via blood (other site of infection)

• rarely: infusate contamination

• direct contamination (catheter & hub by hands)

  • cvc access ports

• prevent by washing hands before interacting w/ CVC

• early infections: skin (extraluminal)

• later infections: hub (intraluminal)

are CVC access ports a contamination source? what should we do? are alcohol impregnated disinfection cap more effective than scrubbing the catheter hub?

• yes

• disinfect with 70% alcohol, scrub the hub with twisting friction for 15-20 seconds before every assess

• yes

CVC access ports caps (what design, when to replace caps)

• caps must be luer lock design (use the right caps)

• replace caps every 7 days or every time removed

• agency policy by functions (ex. after blood draw)

what are biofilms & what can it lead to? how to prevent?

• biofilm- slimy layer for bacteria to stick & forms on medical devices (very hard to kill) & can lead to chronic or device related infections → resistant to antibiotics

• prevent by strict sterile technique, regular line/catheter changes, early removal of devices not needed

why use CHG over povidone-iodine for skin prep before insertion? how long to scrub for?

• gets rid of enough bacteria

• scrub for at least 30 seconds & dry before line insertion

the 4Ts of sepsis (early cognition)

1. trend relevant clinical data (VS, assessment, lab data)

2. temperature (early >100.4F, later hypothermia <96.8F)

3. tachycardia (decreased BP as septic shock progresses)

4. tachypnea >20 per min

how to secure CVC?

use proper statlock device to stabilize

what makes the CVC prone to clots? what to assess for? what should we use

• the external size is not the lumen size aka it gets smaller (big catheter + small lumen + poor flow = perfect for clot formation)

• use smallest lumen necessary

• ensure proper tip placement

• assess for: resistance when flushing, inability to aspirate blood

explain the different types of thrombus: intraluminal clot, fibrin tail, complete fibrin sheath, mural thrombus, occulusive

• intraluminal clot → inside lumen, total/partial block

• fibrin tail → flat at tip, intermittent block (can’t aspirate)

• complete fibrin sheath → encases catheter tip

• mural thrombus → vein wall clot (adheres to vein)

• occulusive → full vein blockage

do we ever force a flush & why?

no b/c risk of embolism, always assess blood return & site swelling (CANT FLUSH = DO NOT FORCE)

intentional rounding of CVC management

• start at insertion site: no redness, swelling, drainage, pain, site stabilized, dressing intact

• correct IV fluid infusing? fluids compatible?

• flow rate (mL/hr) correct for purpose & rx?

• is IV fluid actually infusing on time?

• round: on shift, hourly, after activity, end-shift

• be smarter than the pump

• check tubing: date, kinks, air bubbles, connections

nursing interventions for CVC (what to avoid, implanted port (what to check for, what can we apply)

• avoid checking BP on this arm

• avoid needle sticks on this arm

• use non-dominant arm when possible

• verify compatibility of meds prior to admin

• monitor for SOB & swelling in the extremity

• check for blood return prior to administering med via an implanted port

• apply topical anesthetic cream prior to accessing implanted port

central catheter dressing (what to monitor, how to clean)

• monitor for local & systemic symptoms

  • fever, redness, pain, warmth

• maintain sterile technique

• clean needleless connectors before use

• hand hygiene

• change dressing according to policy & document

central venous access device removal (what do we need to have to remove, when should we remove, how should we remove)

• requires an order from the provider

• remove catheter ASAP → when therapy is complete or sooner if CLABSI is suspected

• remove sutures & gently withdraw catheter

• apply pressure to the insertion site

• examine catheter tip

can we draw blood from CVC? which port do we draw from in multi lumen catheters? which line do we not use? what is the principle for blood draw?

• yes

• preferred distal port b/c closest to superior vena cava

• do not use dialysis lines unless ordered

• principles

  • ensure accuracy of lab test

  • avoid mixing specimen with infusing IV additives

  • ACTION: stop all infusions temporarily to prevent false readings

how to to do blood draw via CVC? (think abt skills)

• stop IV, prep access port, aspirate to check patency

• draw 5 mLs & discard (for lumen w/ heparinized saline)

  • otherwise pt can inadvertently be “bolused” with heparin (IV bolus flush heparin)

• withdraw blood for collection

• needleless blood transfer device (syringe to tubes)

• irrigate with pulsatile “push-pause” method

• hand hygiene → scrub hub → stop infusion → aspirate blood return → waste sample → draw sample → flush → resume infusion → label/document

difference between syringe blood draw vs direct CVC access

• syringe → requires transfer syringe to lab tube (more control & risk of contamination)

  • pink = transfer system required

• direct CVC access → leur lock tip w/ vacutainer sleeve & lab tube (efficiency)

  • blue =direct access

what happens if we use the wrong connector for blood draw?

breaks sterility or damages the sample

method to flush for running lines & capped lines

• running lines: aspirate, flush, administer drug, flush

• capped lines: aspirate & discard, flush, administer drug, flush, heparinized saline