NRSG 301: Central Venous Access Devices

What are CVADs used for?

Administer fluids and blood products

- medications

- vesicants

- irritants

- solutions with extreme pH values

- hypertonic solutions

- obtain venous blood supply's

- monitor central venous pressure

- provide access for pulmonary artery catheters or trans venous pacemakers

- hemodialysis access

- consider length of time client needs IV access

What are characteristics of PVADs?

In periphery

- inserted through forearm, hand, or foot

- can be kept for 72-96 hours

- can be inserted by RNs and LPNs

- can't be used for blood sampling

- can't be used at home for IV therapy

- cost under 200$

- inserted in 10 mins

- flush every shift

- dressing changed prn

What are risks of PVADs?

Infection

- Phlebitis

- Thrombophlebitis

- fluid overload

- arterial puncture

- hemorrhage

- extravasation

What are characteristics of CVADs?

Tip is in superior vena cava

- insertion site can be jugular, cephalic, basilic, brachial, subclavian, femoral

- can be used up to a year

- can infuse 2-3 L a min

- IV nurse can insert PICC but surgeon must do all other while pot is under anesthetic

- can draw blood

- can do home IV therapy

- cost up to 1500$

- takes 30-45 mins to insert

- dressing change every 7 days

- flush every 12 hours

What are the complications of CVADs?

Same as PVAD plus

- catheter embolus

- pneumothorax

- hemothorax

- arrhtmia

- horners syndrome

How long can a non-tunneled CVAD be in place for?

1 week

How long can a tunneled CVAD be in place for?

3 years

How long can a IVAD be in for?

Up to 5 years

What are characteristics of a PICC?

Peripherally Inserted Central Catheter (PICC)

• Where? Inserted in the periphery in the cephalic, basilic or median cubital vein

above the ACF (ante cubital fossa)

• The tip of the catheter rests in the lower portion of the distal superior vena cava

• How? Usually an IV nurse inserts a PICC using an ultrasound machine at the

bedside. Takes about 30 - 45 minutes if all goes well. After inserted the location of

the tip needs to be verified via a chest x-ray

• Dwell time? Frequently used for treatments expected to last between 2 and 6

months (Kozier 2018). 6 months to 1 year is acceptable for use.

• May be valved or non-valved

• May be single lumen, double lumen, or triple lumen

• NB: a blood pressure should not be taken on the arm with a PICC

What's a power injectable?

purple central venous catheter that allows power injection of contrast media for scans (at a maximum rate of 5ml/sec)

Where are non tunneled lines placed?

Subcalvian and internal jugular

What are characteristics of non-tunneled CVADs?

Non-Tunneled Lines

• What? Used for short term and emergent therapy (eg. resuscitation, CVP monitoring)

• Dwell time? Usually left in place less than a week because of increased risk of infection

• Where? Placed in the internal jugular, external jugular, subclavian vein, or femoral vein

• How? Inserted surgically by a physician. Placement needs to be verified by a chest xray

• Are sutured in place (risk of bleeding if pulled out)

• Can be multi-lumen (single, double, triple)

• Surgically by a physician. Verified by CXR.

• Requires a sterile dressing (changed per facility policy)

• Requires heparin flush solution to maintain patency (if non-valved)

What are characteristics of Tunnelled CVADs?

Tunneled Lines

- What and where? Inserted most often in the subclavian vein.

- Proximal end is tunneled subcutaneously from the insertion site (usually 10-15 cm) and brought out through the skin at an exit site

- How? Inserted via surgical incision in the OR or in medical imaging under fluorscopy (placement needs to be verified)

- Dwell time? May be inserted if use is required for over one month. Used for long-term intermittent or continuous access greater than a month.

- It has a Dacron cuff on the tunneled portion of the catheter that is placed under the skin just above the exit site. In 3 - 4 weeks, granulation tissue will grow onto the cuff and create a seal. The seal helps keep the catheter from slipping out and acts as a barrier to infection.

- May be single lumen, double lumen, or triple lumen.

- Can be left in place indefinitely (if no infection, blockage or thrombosis)

- Once site healed, no dressing is needed at home

what is a dacron cuff?

on a tunneled catheter, reduces infection, blocks bacteria, scar tissue holds it in place

What are characteristics of a IVAD?

• What? The port consists of a reservoir, a hollow metal disk with a

self-sealing membrane, and a catheter

• Where? The distal end of the catheter is usually placed in the distal

third of the superior vena cava

• How? Surgically implanted by vascular surgeon into a subcutaneous

pocket usually on the upper anterior chest. Then the line is tunneled

to the vein. Secured with sutures.

• Dwell time? Long-term IV therapy (eg. intermittent medications,

chemotherapy)

• Have a decreased risk of infection

• No dressing required when not being used. If being used needs an

What should you assess on a IVAD?

➢ Assess for dislodging of catheter tip

(neck or ear pain, on affected side,

gurgling sounds, palpitations)

➢ Assess for signs of a dislodged port

(free movement of the port, swelling,

difficulty accessing the port)

➢ Usually flushed at least every 8

weeks when not in use (per agency

policy)

➢ Requires Heparin flush solution to

maintain patency

What is a Hemo-Line?

Hemo-Line

- Tunneled central line. Generally what we see (in IH) a tunneled line used for. Often has a different looking type of end

- Usually used when temporary access needed for hemodialysis (eg. in an emergency or waiting for an AV fistula to heal)

- Usually inserted into the internal jugular or subclavian vein and then into the superior vena cava

- Two types of tunnelled catheters:

- Uncuffed - used in an emergency or for less than 3 months

- Cuffed - used if longer than 3 months

- Usually put in place by a nephrologist, surgeon or a radiologist in the x-ray department or the operating room

- The catheter is usually held in place by a stitch on the skin. If the catheter is going to be used permanently the stitch may be removed once the catheter is firmly in place.

- Different policies exist for care of hemo lines, Hemo RNs only access them

Why is the position of a CVAD tip important?

For subclavian and jugular vein CVADs, the tip of the

catheter should be located within the lower third of the

superior vena cava

What is a valved CVAD?

➢ A venous access device with an internal (integrated) valve or device located at either the proximal or distal end

➢ The valve allows infusion and aspiration through the VAD, but it remains closed when not in use, thus preventing back flow and providing a safety mechanism

➢ There is no need for routine clamping or heparinizing

What is a non valved CVAD?

➢ is a venous access device without an internal (integrated) valve or device

➢ has a clamp to prevent reflux or black flow of fluid contents or blood.

➢ non-valved VADs require a heparin lock to keep patent (eg. heparin 100 units/ml prefilled syringes)

What are the advantages of a multi lumen catheter?

• Ability to administer multiple medications/treatments at the same time

• Ability to administer multiple incompatible medications at the same time

• If more than one lumen, usually at least one lumen is a different gauge (eg. 19g, 20g and 20g)

• VERY IMPORTANT: need to assess and flush each lumen per facility protocol to keep all lumens patent

What lumen colour is used for TPN?

White

What is required to administer TPN through a CVAD?

A CVAD is always used for total parenteral nutrition (a

peripheral line may be used for PPN)

➢ An in-line filter is required

➢ Needs a dedicated line

➢ The white port of a multi-lumen is most often used for TPN

CVAD is often used for TPN

What is a normal CVP? Central Venous Pressure

2-6 mmHg

- Measures right atrial (RA) pressure, and indirectly, right ventricular end-diastolic pressure

What are the roles of the nurse when caring for a client with a CVAD?

Flush volume should be twice the volume of the catheter and add on devices

- lock with heparin

- gauze dressings should be changed every 2 days

- measure from IV site to thicker hub

- over 2 cm need to report to IV team

What should you check at the arm when there is a CVAD?

Swelling. Pain, numbness, tenderness, parasthesia

When should you flush a CVAD that is a continuous infusions?

• Before med administration, blood sample collection, and in between TPN or transfusions

• Before starting TPN or transfusion

• With tubing, extension set, or needleless cap changes

• If retrograde blood observed or occlusion suspected

When should you flush a CVAD when there is an intermittent infusion?

• When converting from continuous to intermittent access

• Before (10mL) and after (20mL) med administration, blood sample collection and in between incompatible solutions or

medications

• Before initiating TPN or transfusion

• Every 24 hours

• If retrograde blood observed within VAD or VAD occlusion suspected

- If a line is not flushing properly or unable to aspirate, need to notify the IV team as soon as possible

What is normal blood ph?

7.35-7.45

What is normal blood osmolarity?

300 mOsm/L

What should the ph and osmolarity be for a PVAD?

5-9 and <600

What should the pH and osmolarity be for a CVAD?

5-9 or osmolarity of over 600 and if is a irritant

What are the signs and symptoms of a catheter related sepsis?

- Local: redness, tenderness, purulent drainage, warmth, edema at the insertion site

How do you diagnose catheter related sepsis?

- Altered vital signs (increased temp, increased HR, increased RR, decreased BP) and altered level of consciousness

- Abnormal lab results (eg. CBC, blood cultures, lactate)

What is the treatment of catheter related sepsis?

- Local: warm, moist compresses and culture of drainage from site; catheter removal if indicated

What are the guidelines for preventing CVAD infections?

Good hand hygiene (before and after palpating catheter insertion sites, before and after inserting, replacing, accessing, repairing, or dressing an intravascular catheter)

What are the signs and symptoms of an air embolism?

- Sudden onset dyspnea, continued coughing, breathlessness, tachypnea, wheezing

What is the treatment of an Air Embolism?

Close, fold, or clamp existing catheter

How can air embolisms be prevented?

Remove all air from syringes, IV administration sets,

needleless connectors, stopcocks, and all other devices added to the CVC.

What is the most common type of occlusion?

Thrombotic

What are chemical occlusions?

non-thrombotic causes of occlusion account for 42% of all

occlusions and are related to medication or drug precipitate. They can specifically be the result of precipitate from the mixing of incompatible medications and solutions or lipid residue.

What are the risk factors for a chemical occlusion?

• Recent infusion of incompatible drugs (eg, heparin, calcium, diazepam, erythromycin, and dobutamine)

• Medications with high-risk for precipitation (eg, phenytoin and cloxacillin)

• High concentrations of calcium and phosphorous in parenteral nutrition solutions

Chemical Occlusions Signs and Symptoms

*Ranging from sluggish and difficult to flush to complete occlusion

*Vary depending on the type of occlusion.

What is the treatment for a chemical occlusion?

• Depends on cause (see agency policy)

• Consult a IV team or MRP- possible instillation of medication to clear line dependent on cause or line replacement

What are mechanical occlusions?

are related to internal or external problems with the CVAD.They include CVAD or tubing kinks, a clogged needleless connector or filter, and incorrect placement of a non-coring needle into an IVAD.

What are examples of mechanical occlusions?

- Kinked tubing

- Cracks or leakage in CVAD

- Constriction of CVAD due to improperly

placed sutures at insertion site

- Catheter tip migration

- Malposition of the catheter

- Closed clamps

(BC Renal

Agency)

- Client position

Mechanical Occlusions may be due to:

- Kinked tubing

- Cracks or leakage in CVAD

- Constriction of CVAD due to improperly placed sutures at insertion site

- Catheter tip migration

- Malposition of the catheter

- Closed clamps

- Client position

What are the signs and symptoms of a Thrombotic occlusion?

• Pain in the extremity, shoulder, neck, or chest

• Edema in the extremity (unilateral arm swelling to distal PICC arm greater than other arm), shoulder, neck, or chest

• Engorged peripheral veins in the shoulder, neck, or chest wall- will only be on one side. Remember how dad said if on two side, more normal, if abnormal, only on one side.

What is the treatment for a Thrombotic occlusion? (for a thrombus that has attached to the CVAD but also altered the vessel wall).

Thrombolysis therapy

• Thrombolysis therapy for luminal occlusions (occlusion inside catheter lumen)– TPA instilled and left to dwell in the catheter by IV team or physician- withdrawn and discarded after dwell.- dissolves fibrin with hopes of restoring catheter patency

• Systemic anti-coagulation used for occlusion Deep vein thrombosis (DVT) treatment with or without CVAD removal usually for 3 months as directed by MRP.

Types of Thrombotic Luminal Occlusions: Intraluminal Clot

There is resistance upon aspiration and decreased ability to infuse fluids.

Types of Thrombotic Luminal Occlusions: Fibrin Tail

• There is resistance upon aspiration as the tail gets “sucked back” over the opening when blood aspiration is attempted, and no resistance when flushing because the tail gets pushed aside by the positive pressure of infusing fluid

• Acts as a one-way valve that permits infusion but not withdrawal of fluid from the catheter

Types of Thrombotic Luminal Occlusions: Mural Thrombus

• Depending on the location of the thrombus, may or may not be symptomatic upon syringe assessment

• Can result in partial or complete occlusion of the vein

• Signs and symptoms include swelling, pain, tenderness, engorged vessels

Types of Thrombotic Luminal Occlusions: Fibrin Sheath

• Inability to aspirate or difficult to withdraw blood, and resistance or inability to infuse fluids

• The fibrin sheath creates a “sock” over the end of the catheter and can continue backwards up the catheter length—***this could result in medication migrating up the sheath and depositing in a smaller part of the vessel where blood flow isn’t adequate for the irritating or vesicant medication. Causing necrosis and tissue damage*****

What are the signs and symptoms of a catheter embolism?

- palpitations, arrhythmias, dyspnea, cough, or thoracic

pain not associated with client's diagnosis or

cormorbidities

How can you prevent catheter embolisms?

Do not withdraw a catheter through a needle during

insertion.

What are the signs and symptoms of a pulmonary embolism?

• Apprehension

• Pleuritic discomfort

• Dyspnea

• Tachypnea

• Cyanosis

• Cough

• Unexplained

• Hemoptysis

• Diaphoresis

• Tachycardia

• Low-grade fever

• Chest pain radiating to neck and shoulders

How can you prevent a pulmonary embolism?

• Do not forcibly flush any CVAD- this could dislodge a clot

• Limit CVAD blood draws- increases risk of clot formation

• Assess patient for s/s of DVT

What is the treatment for a pulmonary embolism?

• Place client on strict bed rest in semi-fowler’s position

• Notify physician immediately

• Monitor vital signs  

• Administer Oxygen  

• Assess CVC for patency (for emergency drugs)

Signs and symptoms of dvt with PICC:

• Dependent swelling to extremity below line

• Percutaneous/tunnelled line—accessory vessel formation on upper chest same side as line

What are the signs and symptoms of a catheter migration?

• Sluggish infusion or aspiration

• Edema of chest or neck during infusion

• Client complaint of gurgling sound in ear with flushing of line

• Dysrhythmias

• Can cause internal vessel damage if CVAD tip has migrated into an accessory vessel

Treatment for catheter migration:

• STOP infusion. DO NOT USE.

• Re-confirm placement with CXR

• Consult with IV team RN or MRP- obtain order to use CVAD

• DO NOT USE until tip position is confirmed

Cause of pneumo/hemothorax:

Caused by accidental puncture of the pleura or lung during CVAD insertion

What are the signs and symptoms of a pneumothorax/hemothorax?

• Respiratory distress (dyspnea, tachypnea, cyanosis)

• Chest or shoulder pain

• Unilateral distension of chest

• Decreased or absence of breath sounds

• Tachycardia

What is the treatment of a pneumothorax/hemothorax?

• Oxygen

• Elevate head of bed

• Call MRP stat if symptoms occured after they have left the bedside.

• Prepare for chest tube insertion

How can CVAD insertion cause arrhythmia?

If the CVAD is advanced into the right atrium,

there is risk of irritating the heart and causing an

arrhythmia

Signs and Symptoms of Arrhythmia:

• Arrhythmia (flutters) (seen on telemetry)

• Abnormal heart rate and rhythm

• Palpitations

What is the treatment for an arrhythmia?

- Oxygen

- remove cause : *(e.g. Repositioning of catheter if able during insertion or removing catheter)

- treat symptoms

Why would a PICC be used to draw blood?

• If a client’s peripheral veins are no longer accessible

• Clinically significant reasons (e.g. risk of hemorrhage, severe needle phobia, client refusal)

• Peripheral pokes for blood draws provide the most accurate results 

What is a concern when pulling blood from a PICC?

Increased risk of catheter-related infection and CVAD occlusion

Can a good blood sample be obtained when being drawn form a PICC?

Not always. Lab results are not as accurate with direct fresh blood access

Which Lumen should be used:

• It is best to use the largest lumen each time, check the lumen gauge indicated on the lumen tubing and pick the 18g if possible.

When should a cap be changed when pulling blood?

After every time blood is removed

Can a student nurse do a blood draw from a PlCC?

Yes

What is the procedure to draw blood?

• Choose largest CVAD lumen (preferably designated- usually the red lumen)

• May use vacutainer for all samples, note: blood culture require a larger adaptor

• Must draw blood in order using a order of draw protocol (blood cultures first, green BC then orange BC, followed by regular tubes- see order of draw in slides ahead)

Blood Draw Procedure: Method 1 (Preferred and **best practice.**)

*Stop infusion (s) wait 2 mins, remove the needless cap, vigorously cleanse PICC port,  attach the luer lock vacutainer adaptor directly to the catheter lumen , if not obtaining a blood cultures, pull off a discard of 10 cc into a waste vacutainer burgundy rubber top) then obtain blood samples in order

• Usually 5-10 mL of blood is discarded prior to taking blood sample or at least three times the catheter volume (an exception is blood cultures)

• Coagulation studies should not be drawn from Heparinized CVADS

• Never pull a discard for blood cultures cuz want the bacteria. For a blood draw, sure, discard amount have to.

Blood Draw Procedure: Method 2

For a capped (SL) CVAD, after vigorous cleansing of cap,  luer lock the vacutainer adaptor directly to the needleless cap if not obtaining a blood cultures  pull off a discard of 10 cc  into a waste vacutainer burgundy rubber top) obtain blood samples in order, and then change the needleless cap following the blood draw (check agency policy)

• Usually 5-10 mL of blood is discarded prior to taking blood sample or at least three times the catheter volume (an exception is blood cultures)

• Coagulation studies should not be drawn from Heparinized CVADS

• Never pull a discard for blood cultures cuz want the bacteria. For a blood draw, sure, discard amount have to.

Blood Draw Procedure: Method 3

Stop infusion for 2 min.  Vigorously cleanse needless cap, Attach 10 mL syringe directly to the needleless cap, draw 10cc of blood into syringe and discard, use another syringe, draw up sample and then attach vacutainer adaptor to syringe to fill blood sample tubes

• Usually 5-10 mL of blood is discarded prior to taking blood sample or at least three times the catheter volume (an exception is blood cultures)

• Coagulation studies should not be drawn from Heparinized CVADS

• Never pull a discard for blood cultures cuz want the bacteria. For a blood draw, sure, discard amount have to.

What order must you do when taking multiple blood samples?

S - Sterile (for blood cultures)

L - Light blue

R - Red

S - SST (Gold but are not used for routine chemistry

except b12 and ionized Ca due to clotting time

requirements)

P - PST (Light green for chemistry and troponin)

G - Green (Dark green = Lithium Heparin for VBGs)

L - Lavender

G - Gray

Stop light red stay put green light go

What should be known about blood sampling?

Each tube contains a different anticoagulant, depending on tests performed

Do not cover the colored stripe with the patient label

Ensure filled to the fill line

Blood Draws continued

- If CVAD is infusing, turn off IV pump for at least 2 minutes

- If requiring multiple blood samples, follow order of draw protocol (red, green, blue, lavender)

- Must draw and discard 5-10 mL (IHA policy is 6 mL) blood prior to sample collection unless drawing cultures

- If drawing for blood cultures, we DO NOT flush to check patency, remove cap, vigorously cleanse PICC/CVAD hub to limit risk of a false positive from skin contamination, attach adaptor or syringe directly to catheter hub and obtain samples (Green BC tube then Orange BC tube (spring then fall)

- Needleless cap is always changed after blood collection

- Post blood sample flush is 20 mL

• Risks - hemolysis, inaccurate coagulation studies if line is locked with Heparin, inaccurate therapeutic drug levels from medication administration and precipitant adhering to inner lumen of line, catheter related blood infection from non-aseptic accessing

• Benefits - decrease risk of hematoma from venipuncture, vein preservation, decreased pain and anxiety from needle phobia

Blood Sampling:

• Each tube contains a different chemicals, depending on tests performed- if done in the wrong order these chemicals can transfer from one tube to the next and skew your results

• Do not cover the colored stripe with the patient label

• Ensure filled to the fill line

When should you change needless caps?

Every 4-7 days

What do you need to know about PICC Dressing Change?

uCare and maintenance of CVADs

uPotential complications related to dressing change (prevention, recognition, treatment)

uMIGRATION

uBLEEDING AT THE SITE

uINTRODUCTION OF CONTAMINANTS                      INFECTION

uACCIDENTAL REMOVAL OF PICC

What should you use for PICC dressing change?

2% chlorhexidine with alcohol pink swab- Make sure it is dried though before putting on a dressing!!! cuz if not, have risk of chemical burn.

Students can change the dressing once signed off

What are key points for CVADs?

1. Dressings should be changed routinely, and whenever the dressing is compromised

2. Change transparent semipermeable membrane (TSM) dressings q 5-7 days. Change gauze dressings q 2 days.

3. Dressings should be labelled with the date, time, and initials of the nurse performing the dressing change

4. Chlorhexidine with alcohol is the preferred antiseptic for CVAD site care (pink chlorhexidine with alcohol swabsticks - make sure to let dry before applying dressing)

5. Use sterile gloves for site care (e.g. dressing changes). Masks are sometimes recommended, but there is no evidence to support their use

6. Cap is changed q7days with dressing change, or if blood visible inside cap and can't be cleared (blood draw or aspirated blood)

What should be known about PICC removal?

● Always verify the physician's order

● Grasp the catheter at the insertion site and withdraw slowly in 2-3cm increments

● Do not apply pressure directly over catheter, support surrounding tissue with sterile

gauze

● If resistance is felt during procedure, stop and apply heat for 15 minutes to upper arm

and shoulder

● Place sterile gauze and large transparent dressing over site

● Maintain sterility at insertion site

What should be known about Jugular or subclavian removal?

- Always verify the physician's order

● Practice Val Salva with patient, deep breath and hold, bearing down

● Position in Trendelenburg without pillows and have patient turn head away, both nurse

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and patient should be wearing a mask

● Don sterile gloves. Use chlorhexidine to cleanse.

● Val Salva maneuver while withdrawing catheter and applying direct pressure over site

with sterile gauze

● If any resistance, stop, tape in place, report to MRP

● Normal breathing while applying pressure for 5-10 minutes without occluding carotid

artery

What should you do post CVAD removal?

Assess site q15min for 1 hour, then hourly for hemorrhage

● Monitor respiratory status q15min for 1 hour for SOB, PE (pulmomary embolus)

● Minimize patient activity for 1 hour, 2 hours for femoral

● If suspected infection of catheter, cut off 1 inch of tip of catheter with sterile scissors and place in sterile C&S container, label and send to lab

● The C&S removal and sampling is often done with 2 people to avoid contamination of catheter tip while maintaining pressure

● Dressing can be removed after 48 hours if no complications