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May 07
Central Venous Catheters
May 07
May 07
Overview of Presentation Differentiates between types List flushing techniques Discuss insertion Describe dressing change procedure Explain procedure for accessing ports Identifies complications Recognize nurse’s role in preventing infection
May 07
http://www.nursing-standard.co.uk/archives/ns/vol14-43/pdfs/4550w43.pdf
Central Venous Catheters
May 07
Types of Central Venous CathetersNon-tunneled-placed
percutaneously directly into vessel. Skin sutured at insertion site. Temporary-usually less than a couple of weeks. Example-triple lumen Arrow
May 07
TunneledSurgically “tunneled”
through tissue, then into vein. Often with cuff that helps decrease infections
Types-Broviac, Hickman, Groshong
What is the difference between tunneled and non-tunneled?
A Hickman® or Broviac® are both examples of tunneled catheters. They are placed in the OR or in interventional radiology (if a doctor inserted it in the ICU, it is not tunneled!). Nurses do not remove these.
When you look at a tunneled catheter, it doesn’t have the “wings” that are used for sutures. Also, you can feel a bump a inch or two away from where the catheter comes out. This is the cuff, a piece of material that grows into the tissue to keep microbes out.
Wings!
No Wings!
This is the cuff
This is not a tunneled catheter
This is a tunneled catheter
May 07
Ports Implanted under skin,
thus must be accessed.
Decreased infection rates
May last months-years Types-Passport, port-
a-cath
May 07
Non coring needle Implanted ports are to
be accessed by non-coring needles only
The use of standard blunt angle needles can lead to degradation of the port and potential for embolization of port materials
May 07
PICCsPercutaneously placed
central catheters
Long catheters placed in arms, legs
Comfortable to patient, but high complication rate from infections, catheter rupture
May 07
Flushing Central Venous Catheters Identify catheter type correctly Use alcohol to prep Smaller than a 10 ml syringe will exert
higher pressure on the catheter. Always apply minimal force to activate a flush.
Must use CVL Heparin order sheets to obtain heparin and chart flushes on MAR.
May 07
Careful!!! Dialysis catheters are locked
with 5000 unit/ml heparin for each lumen. Dialysis catheters can only be accessed by a non-dialysis RN after an order by the renal fellow or attending. Dialysis catheters should only be removed by nurses trained to do so (ICU and Dialysis RNs)
May 07
Insertion Must use full barrier
precautions (mask, hat, gloves, gown, full sterile sheet)
The physician will confirm correct placement. Methods for confirmation include imaging, transducing and ABG sampling
May 07
Maintenance All CVCs must be assessed initially and every 2 hours
thereafter. Document any changes. Tubings, caps are changed q 72 except for TPN with
lipids, which is changed q 24 If new CVL is inserted, new tubing must be used. Leur-lock caps must be used at all times except for
transduced catheters (i.e. CVP) Large bore catheters used for introduction of pulmonary
artery catheters should be removed or changed to smaller lumen catheters when pulmonary artery catheter is no longer needed
May 07
Dressings Change opaque dressings q 24 Change transparent dressings every 7
days or when no longer occlusive Aseptic technique-use CVL dressing kit
with mask Notify MD and Infection Control of
suspected infection Use Chloraprep and Biopatch
May 07
Chloraprep® and Biopatch® Use Chloraprep® on all
patients except ones that have an allergy to it. Not for use during LPs
Biopatch® is not used in the nurseries, but used everywhere else.
Scrub vigorously back and forth, not round and round
Blue side to the skyLine up slit in biopatch with catheter
May 07
Removing CVCs RNs can only remove non-tunneled catheters. Only ICU and dialysis RNs competent to do so
may remove dialysis catheters.
Position patient with head as low as possible. Remove sutures and pull line with steady motion as
patient holds breath or during expiration. Assure tip is present. For PICCs, see measurement
obtained at time of insertion. Hold pressure until bleeding stops, apply dressing.
May 07
Complications-Occlusion Follow occlusion
management protocol as per unit policy
Consult with MD and clinical pharmacist to decide correct solution (for thrombus or precipitate)
May 07
Infection Control
Did you know?
Approximately 90% of catheter related blood stream infections (BSI) occur with central venous catheters (CVC)
Between 500 and 4,000 patients die annually from BSI
Institute for Healthcare Improvement, 2007
May 07
Blood Stream Infections Disruption of the integrity of the skin
creates an avenue for infection
Infection spreads to the bloodstream leading to hemodynamic changes and organ dysfunction and potentially may lead to death
May 07
Institute for Healthcare Improvement (IHI)
Developed in 1991 to improve health care worldwide
Developed improvement measures based on research
Incorporated bundles into the healthcare culture to ensure standardized practice
May 07
What is a bundle???
A bundle is a selected set of elements of care distilled from evidence-based practice guidelines that, when implemented as a group, have an effect on outcomes beyond implementing the individual elements alone
Institute for Healthcare Improvement, 2006
May 07
Central Line Bundle Hand Hygiene Maximal Barrier Precautions Upon Insertion Chlorhexidine Skin Antisepsis Optimal Catheter Site Selection, with
Subclavian Vein as the Preferred Site for Non-Tunneled Catheters
Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines
May 07
Think Outside the Bundle CVL Care
Change transparent dressings every 7 days, those you cannot visualize the site i.e. gauze dressing, change every 24 hours
Change tubing and caps every 72 hours
Cleanse caps prior to tubing change, IVP medication or flushing with alcohol swab
May 07
Insertion Site selection-recommended site in adults is the
subclavian site. For pediatrics-no data. Full barrier precautions should be used-MDs
should use gown, hat, gloves and mask. If you are in and out of the room, wear a mask. If you stand there the entire time, you should use full barriers, too.
Antibiotic impregnated catheters recommended
May 07
Flushing
When flushing multiple lumens, do not use the same syringe for flush.
Properly prep leur-lock injection site-all the time.
Use positive pressure flush to keep line from clotting.
Meticulous technique important…one slip up can introduce pathogens into your patient’s bloodstream.
May 07
Policy 75-A Prior to placement of the line, someone, usually the RN, is
designated to monitor the sterile field and practice. This designee must stop the procedure if the appropriate
steps are not followed. If the patient is conscious, the designee will stop the
procedure by saying “Break Scrub”: indicating to the clinician that the sterile field has been disrupted and the procedure must be stopped.
If the clinician does not stop the procedure, the RN is to document this on the checklist provided and notify the nurse manager.
Find this checklist on the Clinician’s Order site at http://www.musc.edu/cce/ORDFRMS/
Procedure Note & ChecklistProcedure Note & Checklist
May 07
Remember….Try not to let the end of
the tubing hit the floor….
Or take the cap off with your teeth….
May 07 http://www.learnovation.com/johnwise_samples.htm
You can’t be too clean!!!
And, wash your hands!!!!!!!!
CONSISTENCY IS BEST PRACTICE
May 07
CVL Question 1
1 Monitor CVL site and catheter connections on initial shift assessment and assess thereafter:
A At minimum every 8 hours.
B At minimum every 2 hours.
C At minimum every 4 hours.
D CVLs only need to be assessed on initial shift assessment.
May 07
CVL Question 2
2 Personnel involved with CVL placement must adhere to maximum barrier precautions which includes:
A Sterile gloves and a mask
B Sterile gloves, large sterile drape and a mask
C Sterile gloves, mask, sterile gown and cap
D Sterile gloves, mask, sterile gown, cap, and large sterile drape
May 07
CVL Question 3
3 When flushing a CVL you should:A Identify catheter type
B Prep cap with alcohol
C Apply minimal force
D All of the above
May 07
CVL Question 44. Large bore catheters used for introduction of
pulmonary artery catheters should be removed or changed to smaller lumen catheters when pulmonary artery catheter is no longer needed
A T
B F
May 07
CVL Question 55 According to MUHA Occlusion Flow Sheet,
recommended strategies to assist with getting blood return from an occluded catheter include all of the following except:
A Ask patient to deep breatheB Examine catheter for kinksC Place patient in knee chest positionD Forcefully flush CVL
May 07
CVL Question 6
6. The MUHA Heparin order sheet contains orders for both heparin flushes and saline flushes for CVLs.
A T
B F
May 07
CVL Question 7
7 Unless contraindicated, the agent to be used for prepping the site for a CVL insertion is:
A Alcohol
B Chlorhexidine
C Alcohol and betadine
D Betadine
May 07
CVL Question 8
8. Aseptic techniques to prevent CVL infections include:
A Change opaque dressings q 24
B Change transparent dressings every 7 days or when no longer occlusive
C Use Chloraprep and Biopatch if no contraindications
D All of the above
May 07
CVL Question 9
9. A central line “bundle” includesA Hand hygiene and chlorahexadine asepsis
B Optimal site selection
C Daily review of line necessity
D All of the above
May 07
CVL Question 10
10 The recommended site for CVL placement in the adult is
A jugular
B subclavian
C cephalic
D femoral
May 07
CVL Question 11
11 If the sterile filed is broken during CVL placement in a conscious patient, the procedure must be stopped by saying
A The sterile field is broken
B Stop the procedure
C Break scrub
D A mistake has been made
May 07
Congratulations! You have completed the CVL Module!
