Source: Clinical Skills Management of Vascular Access Devices Pre-course handbook. Adapted with permission from NHS Lothian Employee and Education Development Team. Overview of CVADs Type of device Veins commonly used Design Number of lumens Dwell time Flushing requirement Associated complications Peripherally inserted central catheter (PICC) Basilic Cephalic Median Cubital 2 types Valved PICC has no external clamps. Open-ended non-valved has external clamps. Single or double Months up to a year 10ml luer lock syringe or greater. Pulsing action. For flushing solution please refer to local guidelines. Flushed once a week when the device is not in use. Phlebitis Infection Thrombosis Malposition Occlusion Non-tunneled central venous catheter (CVC) Internal jugular Subclavian Femoral Open-ended non-valved has external clamps. Single, double, triple, quad or quin. 10-14 days 10ml luer lock syringe or greater. For flushing solution please refer to local guidelines. Infection Thrombosis Occlusion Pneumothorax AR / AH / CC FINAL 28.4.15
Type of device Skin-tunneled catheter (Hickman / Broviac line) Veins commonly used Internal Jugular Subclavian Femoral Design Open-ended Valved Both have clamps externally Number of lumens Single, double, triple Dwell time Flushing requirement Associated complications Months to years 10ml luer lock syringe or greater. Pulsing action. Positive pressure. Flushed once a week when the device is not in use. For flushing solution please refer to local guidelines. Infection Thrombosis Occlusion Implanted port Internal Jugular Subclavian Femoral Open-ended Single or double Months to years 10ml luer lock syringe or greater. 4-6 weekly flush. Use Huber needle. For flushing solution Infection Thrombosis
please refer to local guidelines. Mid line Basilic Cephalic 10ml luer lock syringe or larger. Infection Occlusion Median Cubital For flushing solution please refer to local guidelines Dougherty, L. (2006) Central Venous Access Devices, Care and Management. Blackwell Publishing. Oxford.
POTENTIAL COMPLICATIONS There are a number of complications that can occur both during and as a result of the insertion of a central venous access device (CVAD). It is the nurse s responsibility to closely monitor the patient for signs of these complications [1] [2]. The complications listed below are those that you may come across in the community once the line is established. Full details of all complications would be discussed on a CVAD course. Potential complication The cause The signs The management Air embolus Caused by poor insertion technique by a lumen being open to air or potentially if a line is accidentally disconnected from the CVC lumen. It is potentially life-threatening as it can lead to cardiac arrest and death. [3] Respiratory distress Sudden collapse Breathlessness Chest pain Tachycardia Hypotension Seek medical help. Lie patient on left hand side and elevate foot of bed (to prevent air moving from right atrium into right ventricle then pulmonary circulation). Oxygen therapy. Chest x-ray. Infection Caused by poor insertion technique and CVAD management. Redness Swelling at site Pain Pyrexia Infected exudates from exit site Prevention and patient / parent education key. Swab site for bacteriology. Blood samples should also be taken for culture and sensitivity - from the CVAD and peripheral. Treatment as indicated. Possible catheter removal if sepsis unresolved following antibiotic AR / AH / CC FINAL 28.4.15
treatment. Potential complication The cause The signs The management CVAD Migration Occurs when the catheter moves from its original position, for example, if catheter is accidentally pulled. It is the nurse s role to check the position of the catheter at every use. Once in situ there should be adequate securement of the device both at the site and also of the external sets. Education of the patient and parent/carer to ensure that it is not pulled and report early if there are any changes to the length of the CVAD. Can be asymptomatic. Partial or complete catheter occlusion. Reduced infusion rate. Signs of extravasation (pain, breathlessness) Swelling of the chest wall. During insertion the position can be rectified. Ultrasound of the jugular vein can indicate malposition in the vessel before an X-ray. X-ray to confirm position of the tip of the CVAD. Line removed. Ear gurgling (described by patients when the CVAD has been positioned in the jugular vein).
CVAD Fracture Due to a faulty VAD set or through wear and tear. During insertion or as a result of the pinch off syndrome (when the catheter becomes trapped between the clavicle and the first rib) rubbing over time may cause the catheter to fracture and an embolism to occur. Not clamping at the correct position on the catheter. Nicking of the catheter when removing sutures. Over screwing of the cap on to the hub or not allowing the cleaning agent time to dry and effectively gluing the cap onto the hub which may cause the hub to crack. The VAD should be flushed and checked by the practitioner inserting VAD before insertion and the nurse should closely observe the catheter for leakage when it is in use. If there is any suspicion of a faulty VAD medical staff should be informed and the VAD removed and replaced. Catheter damage can occur at different points along the catheter. The catheter hub internal fracture. Above or below the catheter hub. The position of the catheter fracture will determine if the catheter can be repaired or needs removing. Prevention is key when caring for CVADs. Use 10ml or large syringes. Avoid the use of small syringes wherever possible. Monitor catheters for cuts, leaks or tears. Check the dressing for moisture or leakage at the insertion site during infusions. Educate the patient for signs. Immediate management is to clamp the catheter and assess the damage. Catheter repair can only be performed for external catheters. This should only be carried out by a skilled practitioner and in accordance with manufactures guidelines.
Datix incident completed and incident recorded in patient records. Thrombosis A thrombosis is a clot of blood that can be present at the tip of a catheter or can surround the catheter. An SVC (superior vena cava) thrombus is caused when the catheter rubs against the wall of the SVC and this provokes thrombosis at the site or a fibrin sheath. No blood return from the catheter. Reduce flow during infusions. Pain in the area. Oedema of the neck, chest and upper extremity. Tachycardia. Prevention: meticulous flushing with pulsatile positive pressure flush. Constant assessment of the function of the catheter. Venogram to diagnose Thrombolytic therapy (Urokinase). Oral anticoagulants. Catheter removal. Breathlessness. Cough. Discoloration of the limb. Catheter Occlusion There are two main types of occlusion: Persistent withdrawal occlusion (PWO) or total occlusion. PWO is when the catheter will flush but not bleed back preventing the practitioner from checking patency. Total occlusion is an inability to withdraw blood and infuse into the catheter. No withdrawal of blood from the catheter. The catheter may or may not flush. Prevention key: Correct flushing procedure Utilising a volumetric pump for infusion management; To ascertain the cause of the occlusion NB: Chemotherapy should NEVER be administered in a line with PWO
until the line has been checked by x- ray or venogram for position or signs of a blood clot or fibrin sheath at the end of the line. Written confirmation should then be documented in the patient s case notes to signify line is safe to use. If IV competent and competent in the management of central lines follow the algorithm for PWO as per unit policy. Routine care of Central Venous Access Devices (CVAD) / Specific advice Before caring for these lines training must have been completed and CVAD competencies achieved. Local policy should be followed when providing routine care to any CVAD. Regardless of the type of CVAD used the principles of care for the device remain the same [4]: To prevent infection To maintain a patent device To prevent damage to the device and associated equipment.
Skin Tunnelled Catheter (Hickman ) / Broviac line) Weekly flushes hepsal 10iu/ml to maintain patency when not in regular use. Weekly dressing change e.g. IV3000. Weekly bionector change. Do not get end of line(s) wet. Child or young person can shower with a central line once the exit site has healed however, should not direct the shower head directly at the line and soak it. Keep line in cotton bag provided or tape onto body when not in use to prevent accidental pulling. No swimming allowed, avoid contact sports. Implanted Port (Portacath ) Monthly flushes hepflush 100iu/ml to maintain patency when not in regular use. No dressing required when gripper needle not in situ. Gripper needle can stay in for seven days. Avoid contact sports.
Trouble shooting Potential problem Action Prevention Accidental removal of central line Cut or break in line Apply pressure with sterile swab at exit and entry site. Inform patient s treatment centre and advise patient to attend treatment centre. Clamp line above break to prevent bleeding. Cover break with a sterile swab or plaster. Seek advice from Paediatric Oncology Outreach Nurse Specialist (POONS) or treatment centre. Keep line in bag or tape onto body in a loop or S shape to prevent accidental pulling. Do not allow children to have scissors when line exposed. Clamp the line in a different place of the designated section every time.
References [1] Hamilton (2006) Complications associated with venous access devices: part two. Nursing Standard 20 (27): 59-65 [2] Woodrow (2002) [3] Heckmann et al, 2000) [4] Royal College of nursing (RCN) (2010) Standards for Infusion Therapy. The RCN IV Therapy Forum. www.rcn.org.uk