1/22/2016. Objectives. Vascular Access Devices

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1 Objectives 1. Discuss selection of appropriate vascular access device based on type and duration of prescribed therapy 2. Demonstrate correct procedure for short peripheral IV insertion including: preparation of patient, site selection and preparation, IV insertion technique, and dressing application 3. Identify the two types of peripheral vascular access devices 4. Identify the four classifications of central vascular access devices (CVAD) 5. Discuss proper maintenance techniques of CVADs including: dressing application, flushing technique, blood drawing, implanted port access/de-access and appropriate CVAD removal Choosing the most appropriate vascular access device for the therapy will result in better clinical outcomes for the patient Important Considerations When Selecting a Vascular Access Device meds of extreme phs 1

2 Catheter Types Non extreme ph 900 Non extreme ph 900 2

3 Short Peripheral IV Catheters Inserted into peripheral veins of the upper extremity Less than 3 long Maximum dwell time 96 hours Indications Short term therapy Non-phlebogenic, non-vesicant solutions/medications Short Peripheral Catheters Care and Maintenance Rotate site every 96 hours and prn Change transparent dressing every 96 hours, or with site change. Gauze dressings, if used, must be changed every 2 days, and prn. Flush with 10 ml NS before and after each medication dose or every 12 hours Blood draws not recommended Short Peripheral IV Catheters extreme ph, or osmolarity greater than 900 mosm/l 3

4 Points to Consider Choose the shortest catheter with the smallest gauge to accommodate the therapy. The larger the gauge number, the smaller the bore of the needle. Therapies and flow rates required in LTC settings rarely dictate the need for an IV catheter larger than 22 gauge Does the patient already have an IV (CVAD) in place? Would a PICC or midline be more appropriate? Check product label for specific lengths and flow rates, as they will vary by manufacturer. Factors Contributing to Vein Damage Rapid cannula advancement Catheter advancement without anchoring skin and vein Insertion of catheter too large for lumen of vein Insertion of catheter close to area of joint flexion Inadequate catheter securement Infusion of hypertonic fluids Infusion of solutions with an extremely high or low ph Rapid infusion of solutions Poor aseptic technique 4

5 Suitable Locations for Short Peripheral Catheter Hand veins to upper arm veins Cephalic and basilic are often best Utilize distal to proximal veins Inspect both arms prior to final selection Consider activities of daily living Ask the patient Palpate the vein. Don t rely on sight alone. Do not use thrombosed or sclerosed veins Vein should be soft, bouncy, fairly straight Tips For Distending the Vein Lower the extremity below the heart Apply a warm compress to arm prior to insertion Apply tourniquet above insertion site (protect skin) Have patient open and close fist Rub gently over the vein in the area of the insertion Light tapping - DO NOT SLAP! Decrease anxiety Provide a warm, comfortable environment Tips for Successful Catheter Insertion Assume a confident attitude Explain the procedure in a way easily understood by the patient Ask for the patient s cooperation in holding his or her arm as still as possible Have someone assist you throughout the procedure, if necessary Assume a comfortable position 5

6 Tips for Successful Catheter Insertion (cont) Insert catheter with bevel up Apply tension to the skin and anchor the vein throughout venipuncture Make a slow, gentle insertion into the vein Decrease angle of catheter when flashback has been obtained Refer to facility s procedure manual for steps for insertion Areas to Avoid Previously used or bruised areas Places of flexion (antecubital and wrist) Avoid catheter insertion within 3 inches of the lateral wrist area Below an infiltrate Near phlebotic areas Areas to Avoid (cont) A bifurcation in a vein A palpable valve Affected arm of axillary dissection (i.e., mastectomy), extremity with poor circulation (e.g., CVA) and arm with AV fistula or shunt Veins of the hands may not be the best choice due to loss of subcutaneous tissue Veins in the lower extremities due to increased risk of deep vein thrombosis (DVT) 6

7 Preparation for Short Peripheral Catheter Insertion Verify physician/lip orders IV medication order Peripheral IV catheter placement Obtain verbal consent Perform hand hygiene Preparation for Short Peripheral Catheter Insertion Gather supplies on a clean work surface Prepare patient Apply tourniquet to identify suitable vein, then release tourniquet Prime needleless connector with extension set, if applicable, with flush syringe Skin Preparation Carefully cleanse skin with Chloraprep at intended insertion site for 30 seconds using a back and forth friction motion Allow to air dry according to manufacturer s instructions This is a no touch technique Do not re-palpate! If you do, you will need to re-cleanse the skin with a new antiseptic applicator and change gloves. 7

8 Insertion Apply tourniquet Prepare catheter per manufacturer s instructions Apply traction to the skin and vessel to keep it from rolling Maintain asepsis Perform venipuncture with bevel at 5-30 degree angle depending on vein depth Blood Return (Flashback) Look for flashback Lower and advance the catheter and needle slightly to ensure the catheter tip (and not just the needle tip) is within the vein Lowering the catheter and needle helps prevent going through the back wall of the vein Advance the catheter Advance the Catheter Thread catheter off stylet into vein Do not pull back on the needle while advancing the catheter Entire catheter must be inserted Never fully remove and then re-insert the needle! Remove the tourniquet to avoid blood flow from the catheter 8

9 Stylet Removal Stabilize the catheter and apply pressure to the vein ABOVE where the tip of the catheter resides in the vein (except with the Nexiva catheter and Introcan Safety 3) Remove needle following catheter manufacturer s instructions for activation of needle safety device Aseptically attach primed extension set/needleless connector with attached pre-filled saline syringe (unless extension set is integral to catheter) Stylet Removal Aspirate the catheter to obtain positive blood return to verify vascular access patency. Flush per physician/lip order. Remove syringe. Observe for swelling, leaking, and/or pain Apply securement device dressing per manufacturer s instructions for use so that insertion site is in the center of the dressing Stylet Removal Secure extension set/needleless connector to prevent accidental catheter removal Clamp extension set Label dressing 9

10 Tips for Peripheral Catheter Removal Loosen dressing and tape prior to removal Do not disturb catheter while removing tape Do not use scissors to remove tape or dressing Pull catheter out parallel to arm/hand Do not apply pressure to site until catheter is removed completely Tips for Peripheral Catheter Removal Apply gentle pressure for at least 2 minutes or until bleeding stops Do not rub site Use a secure, sterile dressing over discontinued site Inspect discontinued catheter for intactness Refer to facility s procedure manual for steps for removal Peripheral IV Catheter Manufacturer Videos BD Nexiva BBraun Introcan Safety 3 (Enlarge the video by hovering over the video, and then click on Go Full-Screen ) 10

11 Practice Questions 1. At what point during the insertion of a peripheral IV catheter does the clinician need to release the tourniquet? a. After inserting the catheter, before checking the flashback chamber for blood b. After verifying the presence of blood in the flashback chamber c. After advancing the catheter in the vein to the hub, prior to removing the stylet d. After the extension set is connected to the hub of the catheter before flushing with NS 2. Which short peripheral IV catheter gauge is suitable for 3 days of hydration in a geriatric patient? a. 14 or 16 b. 18 or 20 c. 22 or 24 d. 23 or 25 Practice Questions 3. The best location for a peripheral IV catheter in the geriatric patient is? a. Lower extremities so they will not accidentally dislodge the catheter b. Large forearm vein: cephalic or basilic c. Axillary vein d. Median antecubital vein 4. Knowing the ph or osmolarity of the drug ordered is NOT important when you consider the best vascular access device for your resident receiving IV antibiotics. a. True b. False Features of Midlines and CVADs Valved vs. Non-Valved Catheters Vascular access devices may be valved or non-valved. Valved catheters are manufactured with pressure sensitive valves integral to the catheter. Midlines and all central vascular access devices may be valved or non-valved. 11

12 Valved Catheters Closed-ended valved catheter: Groshong Slit valve near distal tip of catheter Three way pressure sensitive valve No heparin needed No clamp Valved Catheters Open-ended valved catheter: PAS-V, SOLO Pressure sensitive valve is in hub No heparin needed No clamp Non-Valved Catheters Distal tip open No pressure sensitive valve Requires heparin to prevent backflow of blood into catheter, causing clot formation Non-valved catheters usually have clamps and must be clamped at all times when not in use! 12

13 Power Injectable Catheters Power injectable catheters are designed to withstand the high pressures associated with procedures requiring the use of contrast media. Power rated catheters are manufactured using stronger grade plastics that allow for infusion of solutions at rapid rates of up to 5 ml/second and compatible with pressures of up to 300 PSIs required during contrast enhanced CTs. Power Injectable Catheters (cont) PICCs, implanted ports, tunneled and non-tunneled catheters may be rated for power injection External catheters rated for power injection may have a purple hub, purple catheter and/or purple clamps to help identify them as power injectable. Caution: not all power rated catheters are purple. Other brands have the power rated clearly labeled on the hub or other external part of the catheter. Power Injectable Catheters Power rated implanted ports may have raised tabs that can be palpated on the septum to identify them as power rated ports In the LTC setting, catheters that are rated for power injections are maintained and utilized the same as non-power rated catheters Regardless of power rating, follow prescribed flushing/locking protocols for catheters according to catheter classification Power injectable catheters may be valved or non-valved. Follow prescribed flush based on catheter type. 13

14 Power Injectable Catheters Power injectable catheters may be single or multi-lumen. The lumens able to be used for power injections will be marked. Infusion of solutions or medications in power rated catheters shall not exceed manufacturer s recommendations for the medications or solution being infused. For example: Vancomycin 1 Gram in 250 ml of normal saline infused through a power injectable catheter would still be infused over 90 minutes. With all vascular access devices, information from the referring institution is the best way to identify the type and brand of the catheter. Power Injectable Catheters Midline Catheters Midline catheters may be made of silicone or polyurethane. Midlines may be inserted in the basilic, cephalic or brachial vein. The midline catheter is then advanced into the larger vessels of the upper arm with the distal tip terminating below the axillary vein, but still in peripheral circulation. 14

15 Midline Catheters Are between 8-20 cm long (3-8 ) May be single or multi-lumen Require physician/lip order for placement and reinsertion Informed, written consent is needed Midline Catheters extreme ph Midline Catheters Indications Therapies expected to last 1-4 weeks May be used for therapies appropriate for peripheral administration Limited vascular access Nurse/physician/LIP/patient preference 15

16 Midline Catheters Care and Maintenance Change stabilization dressing/securement device 24 hours after insertion, on admission, then every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Blood draws not recommended Midline Catheters Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Midline Catheters Tips When Utilizing Midlines for Infusion Therapy Always use aseptic technique when caring for or accessing catheter Flush immediately after intermittent infusion to prevent catheter occlusion Use only appropriate flushing devices for flushing midline No BPs or blood draws on arm with midline Measure external catheter length upon insertion, and/or admission, weekly with dressing change and prn If external catheter length increases, do not attempt to re-insert catheter Midline measurement should be clearly documented in patient s chart 16

17 Midline Catheters Tips When Utilizing Midlines for Infusion Therapy Thrombus may cause swelling of arm starting in the fingertips Midline insertion should be considered on the first day of therapy Midline insertion is not a STAT or emergency procedure Mechanical phlebitis can occur up to 72 hours post-insertion Mechanical phlebitis should be treated first, rather than immediately removing catheter Prevention of mechanical phlebitis: Warm compresses for 20 min QID x 2 days Elevate extremity Exercise arm gently Midline Catheters 17

18 Central (CVAD) Infusion catheters which are inserted into and dwell in the major vessels of the body with the tip terminating in the superior vena cava (SVC) or inferior vena cava (IVC). Common to all CVADs May be valved or non-valved May be single or multi-lumen Physician/LIP order is required for placement and reinsertion Informed written consent is needed Central (CVAD) Central (CVAD) Indications Poor peripheral access Therapies expected to last for several weeks, several months, or several years Phlebogenic/vesicant solutions/medications (e.g., Total Parenteral Nutrition, Chemotherapy) Medical history contraindicating ongoing or intermittent peripheral venipuncture Medical conditions requiring frequent venous access Emergency access 18

19 Central (CVAD) Central (CVAD) Contraindications Thrombosis of subclavian, innominate or superior vena cava (SVC) Anomalies of the central venous vascular structures Central (CVAD) Classification of Central 4 classifications Peripherally Inserted Central Catheter (PICC) Non-Tunneled Catheter Tunneled Catheter Implanted Venous Access Device Port Many different brand names Nurses must learn to identify by classification Nurses must identify if catheter is valved or non-valved 19

20 Central (CVAD) Multiple Lumen Catheters Each lumen is a separate catheter and must be maintained individually Allows for simultaneous administration of multiple solutions/medications Allows for simultaneous administration of incompatible solutions/medications Central (CVAD) Considerations Blood draws allowed with physician/lip order (for catheters 4 fr or larger) Flush immediately after intermittent infusion to prevent clotting Maintain positive pressure when flushing All CVADs should be secured to prevent migration, or advancement Peripherally Inserted Central Catheter (PICC) A PICC is a long, thin, flexible (silicone or polyurethane) catheter which is inserted into a peripheral vein with the tip confirmed in the SVC. May be placed at bedside by PICC qualified RN or in Interventional Radiology Veins of choice for insertion: basilic, cephalic, brachial, or medial cubital vein Requires accurate, in depth patient assessment prior to placement 2008 SHEA/IDSA Practice Recommendation: Do not routinely replace 2016 INS Standards of Practice: No recommendation for dwell time Selective devices may be rated for power injection 20

21 Peripherally Inserted Central Catheter (PICC) Contraindicated for patients with history of dialysis shunt/fistula Avoid forearm and upper arm veins in patients with chronic kidney disease stage 4 or 5, unless approved by patient s nephrologist, or physician/lip if no nephrologist involved in care Peripherally Inserted Central Catheter (PICC) Where is the tip supposed to be? According to national guidelines, the tip of a PICC must terminate in the superior vena cava, not in the right atrium, subclavian, or innominate (brachiocephalic) vein If not in the SVC, the tip is malpositioned and should be adjusted. Adjustments are done under fluoroscopy or by a PICC qualified nurse. Tips in the subclavian and innominate veins have a higher risk of thrombophlebitis development Tips in the atrium can lead to arrhythmias Peripherally Inserted Central Catheter (PICC) 21

22 Peripherally Inserted Central Catheter (PICC) Care and Maintenance Change stabilization dressing/securement device 24 hours after insertion, on admission, then every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Peripherally Inserted Central Catheter (PICC) Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy Do not administer medications through a PICC until tip placement is confirmed Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation Always use aseptic technique when caring for, or accessing, catheter No BPs or blood draws on arm with PICC 22

23 Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Measure external catheter length upon insertion and/or admission, with weekly dressing change and prn If external catheter length increases, do not attempt to re-insert catheter PICC measurement should be clearly documented in patient s chart Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Thrombus may cause swelling of arm starting in fingertips Insertion should be considered on the first day of therapy PICC insertion is not a STAT or emergency procedure Mechanical phlebitis can occur up to 72 hours post-insertion Peripherally Inserted Central Catheter (PICC) Tips When Utilizing PICCs for Infusion Therapy (cont) Mechanical phlebitis should be treated first, rather than immediately removing catheter Prevention and treatment of mechanical phlebitis: Warm packs for 20 min QID x 2 days Elevate extremity Exercise arm gently 23

24 Non-Tunneled CVAD A non-tunneled central vascular access device is a catheter that is percutaneously inserted directly into a central vein with tip confirmed in the SVC. Stiffer rigid polyurethane material Often sutured in place Shorter dwell time High infection rate Non-valved catheters should have a clamp on external portion of catheter Non-Tunneled CVAD Veins used for insertion: subclavian, internal jugular, femoral If external catheter length increases, do NOT attempt to reinsert Copy of chest x-ray confirming tip location must be in medical record prior to initial use in facility. If migration occurs, repeat chest x-ray must be done to confirm new tip location prior to use. 24

25 Non-Tunneled CVAD Care and Maintenance Change stabilization dressing/securement device on admission then every week and prn (every 2 days if gauze dressing) Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) Tunneled CVAD A tunneled central vascular access device is a catheter that is inserted into the subclavian or internal jugular vein with the tip confirmed in the SVC and is then tunneled through subcutaneous tissue and exits below catheter insertion site. Surgical procedure Dacron cuff in tunnel allows granulation tissue to form, creating an anchor and barrier to prevent/resist bacterial migration Suture removal days post insertion Tunneled CVAD Initial post insertion assessment must include monitoring both the insertion and exit sites Copy of chest x-ray confirming tip location must be in medical record prior to initial use in facility. If migration occurs, repeat chest x-ray must be done to confirm new tip location prior to use. 25

26 Tunneled CVAD Care and Maintenance Change stabilization dressing/securement device on admission, every week and prn (every 2 days/gauze) Always use sterile technique during dressing changes If separate securement device is present, must be changed with every dressing change Change needleless connector on admission, every 96 hours, prn, and after blood transfusion Tunneled CVAD Care and Maintenance Measure external catheter length upon insertion and/or admission, with weekly dressing change and prn If external catheter length increases, do not attempt to re-insert catheter Tunneled CVAD Flushing/locking protocol: If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) 26

27 Tunneled CVAD Removal of a Tunneled Catheter is a Medical Act! Performed by physician/lip Small incision over cuff may be necessary for removal Implanted Venous Port An implanted venous port is a catheter that is surgically placed into a blood vessel and is attached to a reservoir. The tip terminates in the superior vena cava (SVC). The reservoir is placed under the skin and has a self-sealing septum, or diaphragm. The port is accessed using a percutaneous needle directly through the skin and septum. Venous ports may be implanted in the chest or upper extremity. Once placed, a port is completely covered by skin with no exposed parts. Implanted Venous Port Stainless steel, titanium, or plastic reservoir with silicone septum connected to silastic catheter Self sealing septum allows multiple punctures Available in single or dual ports. A dual lumen port has two separate septums, reservoirs, and catheters. Most ports are placed in the chest and sutured into a subcutaneous pocket created by the surgeon located superficially above the breast tissue, although smaller ports may be implanted into the arm (e.g., P.A.S. Port and X-Port ). If a patient has an implanted port in their arm, blood pressure cuffs and tourniquets should be avoided on the affected arm. 27

28 Implanted Venous Port All ports require accessing/flushing/locking to maintain patency Insertion and removal requires surgical intervention Requires access with non-coring needle (e.g., Huber, Miniloc, SafeStep ) Less alteration in body image Less interference with normal ADLs No dressing required when not in use Long term use (years) Implanted Venous Port Low maintenance when patient not on active infusion therapy Some implanted ports are rated for power injection. Since power injections are not done in the LTC setting, these ports may be accessed with regular, safety non-coring needles. Implanted Venous Port Care and Maintenance Copy of chest x-ray confirming tip location must be in medical record prior to initial use in the facility If accessed: Change non-coring needle and dressing every week Change dressing on admission, weekly and prn during active infusion therapy (every 2 days if gauze dressing) 28

29 Implanted Venous Port Care and Maintenance Always use sterile technique during non-coring needle/dressing changes Flush/lock every month when not receiving infusion therapy, or per physician/lip orders Implanted Venous Port Care and Maintenance Flushing/locking protocol: Implanted Venous Port Care and Maintenance If medication is incompatible with saline, consult with infusion pharmacist for alternate flushing protocol (i.e., D 5 W) The nurse administering the locking must assess the patient for any condition that may require a change in concentration and/or volume of heparin Flush and lock immediately after intermittent infusion to prevent catheter occlusion 29

30 Implanted Venous Port Port Specific Complications Port malposition May be seen after there has been trauma to the port body. One of the major complications that is seen when this occurs is the port flipping over inside its subcutaneous pocket. The nurse will not be able to access the port as the needle will be hitting the bottom (back) of the port reservoir. Should this occur, surgical intervention is needed. If the non-coring needle becomes partially removed from the port body during active therapy, do NOT attempt to push the needle back into the septum of the port. Instead, de-access and re-access per facility policy. Implanted Venous Port Port Specific Complications Port erosion May occur as a result of a misplaced non-coring needle; improper needle length selection, or as a result from a malnourished patient in negative nitrogen balance. Implanted Venous Port Port Specific Complications Extravasation A partially dislodged needle is the most common reason for extravasation. Always assess the needle placement and dressing integrity, especially when vesicants are infusing. In addition, verify the presence of a brisk blood return. If swelling is noted during an infusion, or patient has pain over port during an infusion, promptly stop the medication, assess the patient and follow physician/lip order for extravasation, as needed. 30

31 Implanted Venous Port Port Specific Complications Twiddler s syndrome This is a rare complication that can occur due to the resident s consistent manipulation of the port s body. This manipulation loosens, or breaks, the sutures which were holding the implanted port s body into the subcutaneous pocket. Implanted Venous Port Assessments to be performed before accessing the port: Verify orders: for accessing/de-accessing; flushing solutions/amounts/frequency; blood draws Ensure that the skin over the port is not inflamed, or showing s/s of infection. Do not access if symptoms present, and follow up with physician/lip. Gently assess the mobility of the port Assess the depth of the port body to aid in determining the needle length needed Accessing an Implanted Port Always use sterile technique during port access Perform hand hygiene Gather supplies on a clean work surface Open Port Access Kit Don masks 31

32 Accessing an Implanted Port (cont) Add needleless connector and sterile normal saline syringe to sterile field Don sterile gloves Prep site Attach needleless connector to non-coring needle and prime with normal saline Stabilize port between thumb and forefinger Insert non-coring needle into septum of port, pressing firmly until needle touches the back of the port Never rock or arc needle during insertion Do not rotate or turn needle once accessed Use proper length and gauge of non-coring needle Verify needle placement by aspirating for blood return prior to initiating infusion Secure needle in place with transparent dressing to prevent dislodging Coordinate change of non-coring needle with dressing change every 7 days when port is accessed 32

33 Tips for De-accessing Flush port with appropriate flush/lock solution prior to deaccessing Always wear gloves when de-accessing a port Stabilize port with thumb and forefinger while de-accessing Remove needle slowly with a straight motion. Activate safety feature per manufacturer s instructions. Maintenance of Dressing Change Change stabilization dressing/securement device on admission, every week and prn (every 2 days if gauze dressing) Always use sterile technique during dressing change Perform hand hygiene and don clean gloves and mask Maintenance of Dressing Change Cleanse site Allow to air dry according to manufacturer s instructions (will take longer on hairy areas) Apply new securement device/stabilization dressing Measure external length of catheter, and mid-upper arm circumference (one indicator of thrombus formation) Document dressing change 33

34 Maintenance of Needleless Connector Change Change needleless connector on admission, every 96 hours, prn, after blood draws, and daily with parenteral nutrition. Note: Needleless connector should be changed whenever blood enters the needleless connector. Always prime needleless connector prior to connecting to catheter All lumens must have needleless connector changed at least every 96 hours Maintenance of Needleless Connector Change Vigorously scrub connection with alcohol between hub and needleless connector prior to needleless connector change Clamp catheter if appropriate Remove old needleless connector. ONLY cleanse open hub of CVAD with alcohol if visible exudate/blood present. Attach new needleless connector to catheter hub Document needleless connector change Midline/PICC/Non-Tunneled CVAD Removal Physician/LIP order required May be removed by a qualified nurse per state regulation and facility policy Locate catheter pre-insertion length documented on insertion note. If not available, must obtain specific physician/lip order to remove catheter without knowledge of length. 34

35 Midline/PICC/Non-Tunneled CVAD Removal Place patient in supine position so that the IV insertion site is below the level of the heart Don masks. Perform hand hygiene. Don clean gloves. Carefully remove stabilization dressing/securement device Perform hand hygiene. Don sterile gloves. Cleanse insertion site Midline/PICC/Non-Tunneled CVAD Removal Remove sutures if present Apply antimicrobial ointment to sterile gauze Have patient perform Valsalva maneuver, or take a deep breath and hold during removal. Slowly pull catheter in short strokes until removed. Do not stretch catheter! Apply gauze dressing with sterile antimicrobial ointment over insertion site and apply pressure until bleeding stops Midline/PICC/Non-Tunneled CVAD Removal Apply transparent dressing over gauze dressing Measure catheter and compare to length inserted Instruct patient to remain in supine position for 30 minutes Monitor site for bleeding through the dressing; every 15 minutes x 2; every hour x 2 35

36 Midline/PICC/Non-Tunneled CVAD Removal Document: Reason for removal Total catheter length Site assessment Interventions Leave dressing in place for 24 hours. Inspect and redress site daily until site has epithelialized. Stuck Catheter If resistance is met during removal, STOP! Reposition arm and attempt to remove catheter If still unsuccessful, tape catheter loosely in place with sterile tape. Apple new sterile dressing. Apply warm compress for minutes to dilate vein Attempt again to remove catheter If resistance is met, notify physician/lip Blood Sampling From Central A physician/lip order is required for blood sampling May only be performed by licensed nurse per state regulation and facility policy Catheters/lumens smaller than 4 fr (18g) may be unreliable for blood draws 36

37 Blood Sampling From Central On multi-lumen catheters, the largest lumen is preferred for blood withdrawal after all infusions have been stopped. If all lumens are of equal size, and one is not red or brown, any lumen may be used. Blood Sampling From Central Stop all infusions for at least one minute prior to blood draw. Disconnect the administration set and cover the end with a sterile end cap. Prior to blood sampling, all infusions are stopped for at least one minute. When a multi-lumen catheter is present, all infusions must be stopped but only disconnect the administration set connected to the lumen that will be used for blood withdrawal. Blood Sampling From Central To avoid thrombotic and infection complications, waste blood must NOT be reinfused Therapeutic drug levels may be specifically ordered to be drawn peripherally Always check with the laboratory for the correct order in which to draw the necessary lab work. The order of the draw may affect the results. Certain medications cannot be flushed through the CVAD (e.g., pain management and inotropics) 37

38 Blood Sampling From Central When drawing a sample for blood cultures: DO NOT discard the blood from the first (aspirated) draw. Fill the blood culture tube with aspirated blood from first draw. (Refer to Procedure 5.7 CVAD Culture) Avoid drawing blood from a heparinized CVAD for coagulation studies Vacutainer system or syringe may be used to withdraw blood from a CVAD Blood Sampling From Central The use of a syringe needle to transfer venous blood to a blood collection tube or blood culture bottle is an OSHA prohibited practice. The BD Vacutainer Blood Transfer Device is a single use device to reduce the risk of blood transfer related needle stick injuries while maintaining the specimen integrity. Flush the catheter with 10 ml of NS prior to blood withdrawal to confirm catheter patency and to remove any drug within the catheter before the blood to be discarded is withdrawn Blood Sampling From Central Approximately 5 ml of blood is withdrawn and discarded prior to drawing blood for lab sample Smaller waste volumes are used for neonates, children, and frail patients as ordered After blood withdrawal: Flush catheter with 10 ml NS to remove any residual blood 38

39 Blood Sampling From Central Change primed, needleless connector. Flush with remaining 10 ml NS. Lock per protocol for vascular access device If difficulty in obtaining sample: Have the patient sit up, lie down, turn from side to side, or ask the patient to cough and reattempt to draw Caution: this may also indicate a problem with the catheter s position If still unable to draw sample using a vacutainer, try using a syringe instead To obtain blood sample from a venous port, access the port with a larger, safety non-coring needle (20g) and verify placement by aspirating blood from catheter Vascular Access Device Decision Tree 39

40 Hemodialysis/Apheresis Catheters Hemodialysis Hemodialysis is a method for removing waste products such as potassium and urea as well as free water from the blood when kidney function is inadequate (e.g., renal failure). Hemodialysis/Apheresis Catheters Apheresis Apheresis is the process of temporarily removing blood from the body and separating it into its components. Blood is made up red and white blood cells, platelets, and plasma Some diseases are caused by excessive numbers of these cells and by abnormalities of the proteins and other substances dissolved in the plasma During the apheresis process the unwanted component(s) can be discarded before returning the other components to the body Hemodialysis/Apheresis Catheters Hemodialysis/apheresis catheters are often large-bore, dual lumen tunneled catheters. Short term catheters are often made of polyurethane, and long term catheters of silicone. Apheresis may also be accomplished via large bore short peripheral catheters. 40

41 Hemodialysis/Apheresis Catheters Hemodialysis/apheresis catheters must be clearly marked with tape, or a printed label: Hemodialysis (or Apheresis) Catheter Do Not Access Without Permission Hemodialysis/Apheresis Catheters Care and Maintenance The facility nurse s role in the care of the catheter is: Ensuring clamps are closed, if present Monitoring the integrity of the patient s dressing and needleless connectors. Dressings are routinely changed during the patient s dialysis treatments. If the dressing becomes wet, loose, or soiled, and the dialysis nurse is not available, the licensed nurse may change the dressing. A sterile dressing change must be done as soon as possible. Follow dialysis center s instructions for emergency care and maintenance. Notifying the patient s hemodialysis nurse/nephrologist/lip if complications occur Hemodialysis/Apheresis Catheters Care and Maintenance Because of the large diameter necessary to accommodate the flow rates for hemodialysis and apheresis, flushing/locking protocols are different from other central vascular access devices. Hemodialysis/apheresis catheters are usually locked with higher heparin concentrations to avoid the development of intraluminal thrombosis. The volume used is usually equal to the internal volume of each specific lumen. This high concentration of heparin is withdrawn prior to flushing with next use to prevent heparin bolus. Specific orders must be obtained if the nephrologist/dialysis center wants the catheter flushed/locked and/or dressing changed in the post-acute care setting. 41

42 Hemodialysis/Apheresis Catheters Assessment Any bleeding or drainage at catheter site must be reported to the nephrologist, hematologist, oncologist or dialysis center immediately A smooth edged clamp must remain with the patient at all times In the event of catheter fracture or breakage: Immediately clamp the catheter as close to the chest wall as possible Position patient in bed on left side in Trendelenburg (head down) Notify appropriate physician/lip Arrange for immediate transport to acute care facility for catheter assessment/repair Practice Questions 1. If the IV medication to be infused has a ph of 2.6, it is acceptable to infuse the medication via a midline catheter. a. True b. False 2. To maintain patency of a non-valved PICC, flush with NS only. a. True b. False Practice Questions 3. When selecting the most appropriate vascular access device for your resident, which of the following factors should be considered? a. Length of therapy b. ph and osmolarity of the drug to be infused c. Mental status of the patient d. Condition of the peripheral veins e. History of CVA f. Presence of AV fistula g. All of the above 4. What is the most desirable location for the CVAD tip placement? 42

43 Practice Questions 5. It is acceptable practice to administer medications into a CVAD prior to determining tip location. a. True b. False 6. It is never necessary to change the needleless connector on the unused lumen of any CVAD. a. True b. False 7. The correct technique for CVAD dressing change is aseptic. a. True b. False Next Step Complete Exam Print/Save Certificate of Completion Schedule practicum with your employer 43

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