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44 Terms

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Peripheral Intravenous Cannula (PIVC)

 Inserted into a peripheral vein in the upper or

lower limb

• Generally hand, arm or cubital fossa

• Fluids, medications & blood products

• 14g -24g

• Size required dependent on use

• Max 72 hrs

• If surrounding skin inflamed or swollen do not

use.

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Peripheral Arterial Line

 Inserted in critical care areas for acute monitoring of

blood pressure

• Used for arterial blood sampling

• Inserted into radial artery, less commonly femoral artery

• Seldinger technique

• Caution when transferring patients so as not to dislodge

• If dislodged medical team notified immediately &

pressure applied to arterial site.

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Definition of CVAD

Central venous access devices (CVADs) are

devices that are inserted into the body through a

vein and terminate at or close to the heart, or in

one of the great vessels

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Depending on the CVAD, they can be inserted into one of the peripheral veins of the

upper extremities or into the ___ or ___

subclavian, jugular vein

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CVADs enable the administration of:

fluids

• blood products

• medication

• Chemotherapy

• Contrast

• parental nutrition

• Other therapies to the bloodstream

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Non-tunnelled CVADs

 Central venous catheters (CVCs)

o Peripherally inserted central catheters (PICCs)

o Vascath dialysis catheters

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Tunnelled CVADs

Hickman catheters

o Dialysis catheters (eg.Permacath)

o Portacath

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Peripherally Inserted Central Catheters (PICCs)

A PICC line is a central venous access

catheter that is inserted into a peripheral

vein in the upper arm

• Medium to long term access

• 1-3 lumens

• Size: 4F, 5F, 6F (depending on no.

lumens)

• Administration of central venous fluids,

medications and TPN.

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PICC LINE insertion sites

basilic vein preferable choice,

usually the largest

• brachial vein preferable choice,

sometimes difficult to puncture as it

can be close to or beneath the

artery

• Cephalic vein less common as it is

usually quiet small.

Tip of catheter sits in the superior

vena cava

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PICC insertion Fluoroscopy

• Ultrasound

• Local anaesthetic

• Needle

• Wire

• Sheath

• PICC catheter

• Fluoro screen to confirm

placement

• Secured with statlock and positive

pressure bungs

//

Can be inserted bedside

(ICU)

• Placement confirmed with

ECG or mobile chest xray

• Less reliable

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PICC Complications- insertion

 haematoma

• Infection

• pneumothorax

• Arterial puncture

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PICC Complications- Positional

Catheter dislodgement

• Catheter tip migration

• Thrombus

• Occlusion

• Systemic Infection (Central line

associated Bloodstream infection)

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Power PICC use in CT

The Power PICC is a purple central venous catheter that has

been approved by the FDA for power injection of contrast

• 4Fr single lumen can be injected at 4mls/see,

• 5Fr single lumen at 7 mls/sec

• 5F double lumen at 5 mls/sec

at a Maximum Injector Pressure limit of 325 psi

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Accessing a PICC for CT

• Prior to first use, ensure that position of the tip has been confirmed and the

device is suitable to use.

• Scrub the hub for 15 sec prior to access.

• A CVAD must be aspirated before use

• Contrast can only be power injected through the purple lumen.

• Additional lumens should be labelled ‘no CT’

Positive-pressure valve: Needleless access device

• Enables forward displacement of fluid to prevent thrombus

formation at the lumen opening.

• must be primed before use

• Internal mechanism displaces fluid upon disconnection of a

syringe resulting in a small bolus of fluid from the distal end of

the lumen tip.

• This reduces the risk of catheter occlusion when not in use.

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Flushing a PICC

CVADs should be flushed utilizing a ‘pulsatile’ flushing technique. This

involves pushing 1mL of fluid,

pausing, pushing another 1mL etc. This creates a turbulent flow

clearing the lumen more effectively than a straight flush.

Never use excessive force when attempting to flush a CVAD regardless

of syringe size.

A PICC should NOT be flushed using a syringe smaller than 10mls.

Smaller syringes generate greater pressures which can rupture the device

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Central Venous Catheter (CVC)

 Also known as a Central Line

• Inserted in the internal jugular, subclavian or femoral veins

• Inserted at bedside with ultrasound

• Administration of Medications, blood, TPN.

• Short term access < 10 - 14 days

typically 20-30cm long

• Used for short-term central venous access.

• A CVC may have up to five lumens and may

be antiseptic or antibiotic coated.

• CVCs that are not in use should be flushed

once every 12 hours to help prevent

blockages

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CVC insertion

ultrasound

• Sterile field, gloves, gown and mask

• Seldinger central line kit

• Saline flush

• Chlorhexidine

• Lignocaine Suture

• Scalpel

• Sterile dressing

• Pressure bag to attach to monitoring

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CVC Ideal final position

Distal to brachiocephalic

venous anastomoses,

proximal to right atrium

Inferior border of the

right main bronchus

shadow

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CVC complications

• Infection as catheters inserted into the body make it easier for

bacteria from the skin to enter the bloodstream;

• Thrombus Blood clots forming in the catheter;

• Pneumothorax (collapsed lung) caused by the needle accidentally

piercing the lung during insertion;

• Air embolism caused by air entering the bloodstream through the

catheter. This occurs rarely but is a serious medical emergency.

• Damage to the blood vessel

• Migration of the catheter

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CVC – power injection

• Devices specifically designed for power-injection are

available

• Depends on brand

• generally rated for pressures of 300 psi and flow-rates

of up to 10 ml s−1

.

• Always check external labelling.

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Vascath

• A vascath is a non-tunnelled central venous access device (CVAD),

• Used for short term access

• For dialysis and stem cell collection via apheresis.

• Vascaths are large-bored devices, 13.5F

• Inserted in the subclavian vein, the internal jugular (IJ) vein or the femoral vein.

• Vascaths are usually ‘locked’ with high concentrations of heparin to prevent lumen

blockage and remain clamped when not in use.

• Vascaths should only be accessed by trained dialysis and apheresis staff for these

procedures.

• Usually 1.2 mls heparin per lumen

• It is recommended that vascaths do not remain insitu for longer

than 7 days.

<p>• A vascath is a non-tunnelled central venous access device (CVAD),</p><p class="p1">• Used for short term access</p><p class="p1">• For dialysis and stem cell collection via apheresis.</p><p class="p1">• Vascaths are large-bored devices, 13.5F</p><p class="p1">• Inserted in the subclavian vein, the internal jugular (IJ) vein or the femoral vein.</p><p class="p1">• Vascaths are usually ‘locked’ with high concentrations of heparin to prevent lumen</p><p class="p1">blockage and remain clamped when not in use.</p><p class="p1">• Vascaths should only be accessed by trained dialysis and apheresis staff for these</p><p class="p1">procedures.</p><p class="p1"></p><p class="p1">• Usually 1.2 mls heparin per lumen</p><p class="p1">• It is recommended that vascaths do not remain insitu for longer</p><p class="p1">than 7 days.</p>
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Vascath Ideal final position

Subclavian/IJ approach:

Cavo-atrial junction

Femoral approach: Distal to common

iliac venous anastomoses

<p>Subclavian/IJ approach:</p><p class="p1">Cavo-atrial junction</p><p class="p1">Femoral approach: Distal to common</p><p class="p1">iliac venous anastomoses</p>
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Tunneled CVADs

 Permacaths

• Hickmans

• Ports

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Advantages of tunnelled CVADs include:

Lower infection rate

• Longer duration

• Less mispositioning

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Tunnelled CVAD insertion

• US is used to puncture the jugular vein followed by

wire and small sheath.

• A small pocket is made in the chest wall, and the

catheter is tunned through, under the skin until it

emerges at the jugular puncture site.

• It is then inserted thought the sheath into the

jugular vein.

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Permcaths

 A permacath ( or permcath) is a type

tunnelled central venous access

device.

• It is a split catheter – this means that

the two lumens have unequal

lengths

• One opening is a few cm distal to

the other to give a staggered

opening

• Permacaths are used for dialysis

• Long term access (months - years)

• Wide bore catheter, 14.5 F

• Various lengths 19cm -31cm

• Sutured in place

• Inserted by a radiologist in angio

• Given the patient’s dependence on this therapy, these devices must not

be accessed outside of dialysis unless urgent access is required and this

has been authorized by a medical lead.

• Dialysis catheters must only be accessed by renal trained clinicians.

• Be aware that dialysis catheters are usually ‘locked’ with high

concentrations of heparin to prevent blockages.

Non-accessible cap:

To deter inappropriate access of dialysis-

dedicated devices by clinicians who are

not dialysis-trained.

<p>&nbsp;A permacath ( or permcath) is a type</p><p class="p1">tunnelled central venous access</p><p class="p1">device.</p><p class="p1">• It is a split catheter – this means that</p><p class="p1">the two lumens have unequal</p><p class="p1">lengths</p><p class="p1">• One opening is a few cm distal to</p><p class="p1">the other to give a staggered</p><p class="p1">opening</p><p class="p1"></p><p class="p1">• Permacaths are used for dialysis</p><p class="p1">• Long term access (months - years)</p><p class="p1">• Wide bore catheter, 14.5 F</p><p class="p1">• Various lengths 19cm -31cm</p><p class="p1">• Sutured in place</p><p class="p1">• Inserted by a radiologist in angio</p><p class="p1"></p><p class="p1">• Given the patient’s dependence on this therapy, these devices must not</p><p class="p1">be accessed outside of dialysis unless urgent access is required and this</p><p class="p1">has been authorized by a medical lead.</p><p class="p1">• Dialysis catheters must only be accessed by renal trained clinicians.</p><p class="p1">• Be aware that dialysis catheters are usually ‘locked’ with high</p><p class="p1">concentrations of heparin to prevent blockages.</p><p class="p1"></p><p class="p1">Non-accessible cap:</p><p class="p1">To deter inappropriate access of dialysis-</p><p class="p1">dedicated devices by clinicians who are</p><p class="p1">not dialysis-trained.</p>
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Hickmans

A large bore vascular access device commonly inserted into

the subclavian vein and tunneled through subcutaneous

tissue prior to exiting the body.

Commonly used for stem cell transplant, chemotherapy or when long-

term central venous access is required.

Anchored subcutaneously via a cuff attached

to the catheter.

• Sutured insitu

• Wide bore 9.5, 12F

• May be single, double or triple lumen.

• heparin-locked when not in use.

<p>A large bore vascular access device commonly inserted into</p><p class="p1">the subclavian vein and tunneled through subcutaneous</p><p class="p1">tissue prior to exiting the body.</p><p class="p1">Commonly used for stem cell transplant, chemotherapy or when long-</p><p class="p1">term central venous access is required.</p><p class="p1"></p><p class="p1">Anchored subcutaneously via a cuff attached</p><p class="p1">to the catheter.</p><p class="p1">• Sutured insitu</p><p class="p1">• Wide bore 9.5, 12F</p><p class="p1">• May be single, double or triple lumen.</p><p class="p1">• heparin-locked when not in use.</p>
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Hickmans Insertion

Inserted by radiologists on angio suit

• Inserted under local anesthetic with conscious sedation

• Tunneled catheter

• Cut to length internally

• Cuff sits at skin entry site.

• Flushed with 5mls 50,000 heparin per lumen

• Closed bung attached

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Portacath

A totally implanted vascular access device. Made up of a

silicone covered chamber that is attached to a large bore

catheter. The chamber sits under the skin and the catheter sits

in a central vessel.

• Commonly used when long-term central venous

access is required.

• 6F, 8F size

• Single lumen ports are the most common, however,

double lumen ports are available that have two

separate chambers.

• Inserted in the chest or upper arm.

• heparin-locked when not in use.

A port must be accessed with a specially

designed, non-coring needle (a port-specific

needle that will not damage the port

chamber).

Different non-coring needles are required for

pressure injectable ports – these are labelled

with how many mls/sec can be injected.

These specialised non-coring needles can be

used with any port, whether pressure

injectable or not

<p class="p1">A totally implanted vascular access device. Made up of a</p><p class="p1">silicone covered chamber that is attached to a large bore</p><p class="p1">catheter. The chamber sits under the skin and the catheter sits</p><p class="p1">in a central vessel.</p><p class="p1"></p><p class="p1">• Commonly used when long-term central venous</p><p class="p1">access is required.</p><p class="p1">• 6F, 8F size</p><p class="p1">• Single lumen ports are the most common, however,</p><p class="p1">double lumen ports are available that have two</p><p class="p1">separate chambers.</p><p class="p1">• Inserted in the chest or upper arm.</p><p class="p1">• heparin-locked when not in use.</p><p class="p1"></p><p class="p1">A port must be accessed with a specially</p><p class="p1">designed, non-coring needle (a port-specific</p><p class="p1">needle that will not damage the port</p><p class="p1">chamber).</p><p class="p1">Different non-coring needles are required for</p><p class="p1">pressure injectable ports – these are labelled</p><p class="p1">with how many mls/sec can be injected.</p><p class="p1">These specialised non-coring needles can be</p><p class="p1">used with any port, whether pressure</p><p class="p1">injectable or not</p>
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Portacath indications

Long term intravenous use

• Administration of chemotherapy

• Intravenous medications and fluids

• TPN

• Blood products

• Repeat blood sampling

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Portacath insertion

Inserted in angio by an interventional radiologist.

• Two small cuts (incisions) will be made in the skin.

• The first is to access the IJV

• The 2nd is made to create a pocket under the skin for the

port.

• It will be about 3–4cm long. If the port is being put into a

vein in your chest, the incisions are made on your upper

chest.

• If the port is being put into a vein in your arm, they will be

on the inner side of your arm.

• The tube attached to the port will be tunnelled under the

skin and inserted into the IJV

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Portacath – Power injection

nNot all ports are power injectable

• Important to check prior to use

• Ports can be accessed by appropriately trained nurses and medical staff

• Once accessed can be used by any staff appropriately trained to administer IV medications

• Different non-coring needles are required for pressure injectable ports

• these are labelled with how many mls/sec can be injected.

• These specialised non-coring needles can be used with any port, whether pressure injectable or

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Tunnelled catheter complications insertion

Insertion

Puncture site haematoma

Infection

Perforation

Kinked catheter

Pneumothorax

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Tunnelled catheter complications Positioning

Fibrin sheath

Too proximal – Brachiocephalic venous

thrombosis

Too Distal – arrhythmia

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Tubes & Drains

 NG tube

• ET tube

• ICC

• Nephrostomy

• Biliary drain

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Nasogastric Tube

A NG tube is a soft flexible tube passed through the nose, down the throat and into the

stomach, it is used for the:

• Suction of gastric contents

• Delivering nutritional support and medications

• Gastric washout prior to surgery

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NGT Complicatiosn and ideal pos

Complications

• Aspiration

• Intracranial perforation

• Pneumothorax

Ideal position

Dual purpose – Distal

to the gastro-

oesophageal junction,

proximal to duodenum

For feeds only – Third

part of duodenum

(Horizontal segment)

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Endotracheal Tube

Ventilation of respiratory compromised

patients

• Various sizes 6,8,10,12F

• Anchored externally to the mouth or nose

• Inserted by anaesthetist/ trained medical

• Positioned at least 4 cm proximal to

tracheal carina (usually 6-8 cms)

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Endotracheal Tube complications

 Aspiration

• Pharyngeal perforation

• Oesophageal Intubation

• Malpositioning too high/low

• Over inflated balloon

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Intercostal Catheter (ICC)

 An intercostal catheter (ICC) or chest tube is put in between

the ribs into the space located between the lung and the chest

wall (pleural space).

• The chest tube drains the air or fluid/blood from the pleural

space.

Chylothorax: Collection of lymph fluid in the pleural space

Haemothorax: Collection of blood in the pleural space

Pneumothorax: Collection of air in the pleural space

Chest drains should not be clamped unless ordered by medical staff

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icc Ideal final position

To evacuate air – Most non-

dependant portion of the

lung

To evacuate fluid – Most

dependant portion

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Surgical drains

Jackson-Pratt drain (JP drain) commonly placed post operatively to

drain fluid/blood from surgical site

• Nephrostomy is a drain tube inserted into the renal collecting system

to drain urine away from the urethra and bladder.

• Percutaneous biliary drainage catheter is inserted into the bile ducts in

the liver via a direct puncture through the abdominal wall

When transferring patients always be very careful to check for drains

and attachments.

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Lines, tubes & Drains cont.

Oxygen

• Urinary catheter

• PIVC

• Art lines

• CVADS

• Ventilated patients

• Chest drains

• Feeding tubes

• Surgical drains

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overview

ETT

NGT

Central line

Right subclavian CVC

Vas Cath

ICC x 4