Week 3: Central Venous Access Devices

Central Venous Catheter

Purpose of Central Venous Catheters

• IV therapies requiring hemodilation (high osmolarity)

>10% dextrose, hypertonic solutions that damage veins, greater than 600, >5% protein, increase electrolytes

• Frequent or prolonged IV (chemo)

• Frequent blood work or transfusions

• Large-bore venous access required

• Pressure monitoring (Central Venous Pressure or cardiac output)

• Lack of alt. access

• Incompatible meds/ medicated gtts

Non-tunneled

• urgent situations (secured with sutures)

• inserted percutaneously at the bedside → subclavian, internal jugular; need X-ray but not for femoral

• Multiple lumens (2,3,4)

• Short access (2-4 weeks)

• Highest risk of infection (because it’s very short)

Tunneled

• Requires surgical/radiological placement and removal

• secured with Dacron Cuff (fibrous tissue growth to secure)

• Long term use (1-3 YEARs)

• Low risk of infection

• “Broviac”, “Hickman” = brand names

Can palpate underskin until venous entry point

Peripherally Inserted Central Catheter (PICC)

Is most likely to hit Right Atrium (cause tachycardia, arrhythmias)

• Inserted via a peripheral vein (basilic, median cubital, brachial, or cephalic)

• Are recommended for all infusion therapies for up to ONE YEAR

• may be inserted at bedside or in radiology under fluoroscopy

• Radiographic (X-ray) confirmation of tip location is required prior to use

• Various types — Closed or Open

→ Open - Power PICC, “Arrow” — open end, clamps (can cause turbulence with blood flow = clots, flushing with saline and heparin/anti-coagulant)

→ Closed - “Groshong”, Power PICC solo — valve end, no clamps on line (flush with saline)

Implanted Venous Access Device (IVAD)

• inserted in OR

• long term therapy of 1 to 3 years

• must be accessed with a Huber Point Needle (non coring)

→ if accessed, needle must be changed Q7 days

→ If not accessed, needle must be inserted and port flushed with heplock solution q30 days

→ Palpate for firm disc on chest

Dressings: Change and Assessment

Completed:

• q7 days

• visibly soiled

• dressing peeling off

• 24hour post insertion

Sterile technique:

• use of chlorhexidine

• sterile gloves and masks for dressing change

• Remember: any tape, skin closure strips or securement device applied under dressing MUST be sterile

• securing device

Site Assessment

• q4h when inserted — redness, tenderness, leakage

• then q shift — palpate cover for tenderness, drainage, streaking

Equipment

• heplock syringes x 10mL prefilled x # of connectors/lumens

• caps

• IV tubing to patients central line

• procedural mask for you and patient

• gloves

• Stat lock if secured with

• chlorhexidine swabs

• measuring device to measure hub to insertion site

Flushing

• CVADs must be flushed to maintain patency

• Completed under aseptic technique

• One pre-filled 10mL syringe for each lumen (less than = too much pressure unless wide head)

• Scrub needless connector for at least 15 seconds

• Aspirate and discard any locking solution if other than NaCL 0.9%, low does Heparin or sodium citrate

• Slowly aspirate for blood return

• Use positive pressure with 10cc syringe

• Never force flush - assess!

Locking

Locking frequency

• non-tunneled CVAD = q24h

• tunneled CVAD = q7 days

• PICC = q24h

• IVAD = q30 day when not in use

Solutions

• valved catheters (closed PICC, tunneled CVAD) - NS 10mL

• non-valved (open) - NS 10ml with heparin (10u/ml) 5ml OR sodium citrate 4% 3ml

AHS/CovH - may be NS only - check your unit

Key Points for Locking

• not for paediatrics/neonates or hemodialysis/aphaeresis lines

• Situations where heparin may still be required (in consultation): history of line occlusion, catheter infection, long term CVAD use (>3months), specialty CVADs (e.g. dialysis, aphaeresis)

Cap Connector Change

Frequency

• no more than q96h but at least q7 days

• prior to collection of blood culture samples from a CVAD

Procedure

• prime connector using aseptic technique

• scrub the needless connector/catheter lumen connection junction vigorously for min 15s

• Remove connector using sterile gause/aseptic technique

• Clean threads of hub if soiled

• Attach new connector

• Flush and Lock