COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Treatments POLICY NUMBER: 428 Effective Date: August 31, 2006 SUBJECT: CENTRAL VASCULAR ACCESS DEVICES (CVADs): CARE AND USE 1. PURPOSE: To ensure safe needle insertion procedure and maintenance of adequate access via the Port-A-Cath or other CVAD. 2. POLICY: 1. Accessing a Central Vascular Access Device must ONLY be done by a qualified RN, MD or Doctor of Osteopathic Medicine (DO), using aseptic technique. 2. The physician may only order a 1:1 with documentation supporting the specific necessity for the 1:1/ such an order will be for a period not to exceed 24 hours. The order may only be renewed after the physician personally sees/reevaluates the individual and documents the necessity for the 1:1 prior to re-ordering it. 3. COMPETENCY: When an individual with a CVAD is received on a unit, RN(s) of that work site will receive in-service training from the staff Development Center and will be provided a competency review and approval by the designated medical surgical physician. The unit supervisor will assure that all unit staff is aware of safety precautions for individuals with central vascular access devices. 4. DEFINITIONS: There are four major types of Central Vascular Access Devices (CVAD): 1. Non-tunneled Catheter - Large-bore catheter inserter into the sub-clavian vein, 6 to 8 inches long. Can have from one to four lumens, and are made of either soft silicone or stronger polyurethane. Of the four types, these have the highest infection rate. -1-
2. Tunneled Catheter Designed for long-term use, made of durable, medical-grade silicone, can remain in place for many years. (Examples: Hickman, Broviac, Groshong, Hohn, and Leanard catheters.) 3. Peripherally Inserted Central Catheter (PICC) Lines Inserted in a peripheral vein and threaded into the superior vena cava, best suited for individuals requiring daily infusion therapies for up to 6 months. Longer than other CVADs (20 to 25 inches, as opposed to 6 to 8 inches). 4. Implanted Ports Totally implanted under the skin, this type has no external parts. Considered a long-term CVAD, may last for 2,000 punctures. Best used for cyclic therapies (e.g. chemotherapy or antibiotics) and for treatments for chronic or long-term illnesses (e.g. cancer or cystic fibrosis) 5. GENERAL INFORMATION: Central Venous Access Devices are not inserted at this facility, however an individual may return from an outside facility with any one of these devices in place. The following information applies to al four types. 1. The tip of a CVAD should rest in the superior vena cava, with one exception: the tip of a femoral line rests in the inferior vena cava. Infusing medication through misplaced catheters can cause significant injuries, including pericardial effusion and cardiac tamponade. Placement in the right atrium is not acceptable for any device; the tip could trigger an arrhythmia as it floats across the senatorial (SA) node. A catheter tip migrating through the heart may become entangled in the tricuspid valve, necessitating valve replacement surgery. 2. For PICC catheters, measure the external length and document it for comparison with subsequent measurements. If there is any change at ll, notify the physician immediately. 3. Before using any CVAD, make sure that an X-ray had verified correct tip placement. The radiology report should confirm tip placement in the superior (or inferior) vena cava, or the junction of the right atrium and the superior vena cava (atrial/caval junction). This information should be on the intake and output flow sheet, and/or the medication administration record. Obtain blood return the CVAD before each use. 4. Flush the catheter routinely to remove any drug residue from the lumen and prevent the catheter from clotting if blood refluxes into the lumen. Use the SCSH method: Saline, Administer the drug (or withdraw blood). Saline, Herparine. Flush any CVAD using the positive-pressure technique: inject the flush solution, leave your thumb on the syringe plunger, and close the clamp. This helps prevent blood backflow and lowers the risk of catheter occlusion. -2-
Most CVADs have a volume of 1 to 3 ml, and should be flushed with a volume that is at least twice the volume of the catheter and extension tubing. Use only 10-ml or larger syringes. 5. Remember the larger the syringe barrel, the lower the pressure. Using a small barrel, hih-pressure syringe will increase the chance of breaking the catheter. 6. Use a 10-ml or larger syringe to obtain a blood specimen. Vacuum bloodcollection systems may also be used with all CVAD s except PICC lines. These generate extremely high pressure that can rupture PICC catheters. Discard the first portion usual 5 to 10 ml of the blood specimen to prevent heparin or a drug from contaminating the specimen and causing inaccurate lab results. 7. The external end caps on NON-TUNNELED and TUNNELED CVAD s should be changed at least once a week. Check the manufacturer s recommendations for guidelines specific to the device. (NOTE: this does not apply to IMPLANTED PORTS, which do not have an external end cap.) To access an IMPLANTED PORT, you will push a special non-coring Huber needle through the skin. A traditional needle would core the septum, resulting in blood leakage and contact with air. A damaged port must be surgically removed immediately. 6. PRECAUTIONS: Many nurses incorrectly believe that transparent dressings are occlusive. These semi permeable membranes permit air to circulate through the dressing to prevent perspiration from collecting under the dressing. To make a transparent dressing occlusive, apply povidine-iodine ointment or antibacterial ointment to the site. The jellylike consistency of ointment occludes the wound. 7. FREQUENCY: Gauze Dressing Should be changed at least every 48 hours, whenever the dressing is no longer intact, and/or if you lift a gauze dressing to inspect the site, you must replace it. Transparent Dressing Should be changed every 3 to 7 days, or whenever the dressing is no longer intact. 8. EQUIPMENT: 1. One opsite (transparent) dressing. -3-
2. One alcohol swab stick 3. One beta dine swab 4. 4x4 gauze 9. PROCEDURE: 1. When changing a dressing, wash your hands, put on non-sterile gloves and remove the old dressing. 2. Discard the dressing and the gloves as per policy. 3. Wash hands, set up supplies, and don sterile gloves. 5. Inspect and palpate the catheter insertion site for swelling, redness, or any other sign of complications. 6. Then vigorously clean the same area with povidine-iodine and let the skin dry completely. 7. Apply new dressing. 10. SPECIFIC TYPES OF CVADs: The following pages list each of the four major types of central venous access device and the specific care and maintenance required for them. 1. Non-tunneled 2. Tunneled 3. PIXX Lines 4. Implanted port (e.g. port-a-cath) No tunneled CVAD Fast Access : General Information: Nontunneled CVADs can be inserted quickly and can handle any kind of I.V. therapy as well as blood collection, making them especially useful in an emergency. Some types are impregnated with heparin, chlorhexidine, or an antibiotic. Insertion Information: Usually inserted by a physician (although a specially prepared nurse practitioner or physician assistant may do so in some circumstances). Observing strict aseptic technique, the practitioner first inserts a 14-gauge needle into the subclavian vein, using the clavicle as a guide. When venous blood return is observed in the syringe, the syringe is disengaged from the needle, and a wire is fed through the needle into the subclavian vein. The needle is then removed and discarded, and the catheter is fed over the wire -4-
into the subclavian vein and the brachiocephalic vein. After insertion, the site is covered with a dressing to prevent microorganisms from entering the venous system via the insertion site. Note: Out of the four types of CVADs, this type has the highest rate of infection, so meticulous nursing care is crucial. Nursing care and use: 1. Obtain blood return from a non-tunneled catheter (and any other CVAD) before each use. 2. Flush the catheter routinely to remove any drug residue from the lumen. Use the SCSH method whenever flushing a catheter. 3. If the catheter is not in use, flush it once a day with heparin. 4. Most CVADs have a volume of 1 to 3 ml; flush with a volume that is at least twice the volume of the catheter and extension tubing. 5. Flush any CVAD using the positive-pressure technique. 6. Use a 10-ml or larger syringe to abtain a blood specimen. Discard a portion (usually 5-10 ml) to prevent heparin or another drug from contaminating the specimen. 7. You may use a vacuum system for drawing blood from this type of CVAD. 8. Change the end caps of the catheter at least once a week, or follow the manufacturer s recommendation specific to the device. Tunneled CVAD Catheters that stay awhile: General Information: Designed for long-term use, these catheters can remain in place for many years. Chronically ill individuals who require long-term I.V. therapy are candidates for these catheters, which are made of durable, medical-grade silicone to help avoid breakage. They are ideal for active individuals: once the catheter tunnel and cuff matures, these individuals can move about without restriction. Insertion information: Inserted by a physician in the operating room or interventional radiology suite, using a needle to locate the subclavian vein and advancing the catheter tip into the superior vena cava. The physician then utilizes a blunt-ended trocar to create a subcutaneous tunnel from the subcalvian vein down the chest wall. Catheter manufacturers recommend that the catheter exit the tunnel at the nopple level. Once the cuff heals into place, the sutures can be removed and no dressing is required unless the individual is immunocompromised and at high risk for catheter infection. -5-
Nursing care and use: -For the first 10 days after insertion, change a transparent dressing weekly, or whenever soiled or loose, use aseptic technique. -Change gauze dressings every 48 hours or whenever soiled or loose. -Once the cuff heals into place (and sutures are removed) a dressing is not necessary, unless individual is immunocompromised. -Teach individual to wash the catheter exit site with soap and water when showering and to inspect and palpate the site daily for signs of infection. -Most tunneled catheters should be flushed with 3 to 5 ml of heparin (10 units/ml) daily when not in use, and before and after each use, using the SCSH protocol [see general information section, page 435.2]. -EXCEPTION: closed-ended (groshong) catheters hav an internal valve designed to prevent blood reflux into the catheter. The manufacturer recommends less-frequent flushing with saline, not heparin. [See next page] -Blood may be drawn from tunneled catheters using a 10-ml (or larger) syringe or vacuum collection systems. -As with non-tunneled catheters, change end caps at least weekly. -Manufacturers of tunneled catheters provide repair kits if the catheter s external portion breaks. Closed-ended or Groshong-type tunneled catheters: -Are designed to prevent backflow into the catheter when the catheter is not in use. -Fluids infuse though a slit valve on the side of the tip; when no infusion is flowing, the slit valve on the side of the sip; when no infusion is flowing, the slit valve remains in a neutral or closed position. -A back plug on the end of the catheter opens inward during blood aspiration and outward during an infusion and remains closed at other times. -Because of this design, DO NOT CLAMP as closed-ended catheter (e.g. when attaching extension tubing), as you would with traditional open-ended CVADs. The pressure from clamping could force the slit valve open, allowing bloo to leak into the lumen. -The catheter tip design protects the catheter from clotting; therefore routine flushing with heparin is not required. -Flush this type of catheter with 5 ml of 0.9% sodium chloride before and after each use and weekly if the catheter is not in use, as recommended by the manufacturer. PICC catheters another option for the long haul: General Information: -6-
This type of catheter is inserted into a peripheral vein and threaded into the superior vena cava. They can be used for all therapies and blood collection, and are best suited for individuals who require daily infusion therapies for up to six months. No recommended maximum dwell time has been established, and some individuals have used a PICC line for a year or more without any problems. PICC lines (such as #2 or #3 French catheters) may be difficult. Theses catheters also tend to infuse fluids more slowly and occlude faster then other CVADs. However, the incidence of a catheter-related infection is only about 1%. Insertions information: PICC catheters can be inserted by a physician or a specially prepared nurse in various settings. Before starting, the physician measures the individual to make sure the catheter is the correct length to reach its destination. It is then inserted into a vein in the antecubitin fosse (e.g. the basilica or cephalic vein), and advanced into tie superior vena cava. In some instanced, a PICC line is advanced only into the peripheral vasculature, in which case they are considered peripheral or midline catheters, not CVADs Nursing care and use: - After insertion, a transparent dressing is applies to the insertion sire so it can be observed without disturbing the dressing. -Proper placement of the catheter should be confirmed by x-ray. -Change the dressing 24 hours after insertion, then every 7 days or sooner if it becomes soiled or loose. -Measure and document the external length of the catheter with each dressing change. -If there is any change in the external length, notify physician immediately and recommend x-ray to check catheter position. -The purpose of a PICC dressing is twofold: 1. To anchor the catheter in place. 2. To act as a bacterial seal. -When applying a dressing, place the securing device on the catheter hub. -Most PICCs are open-ended and vulnerable to catheter occlusion. -Flush open-ended PICCs with heparin, 100units/ml (total volume, 3ml), after each use following the protocol. -Flush daily when not in use. -Follow manufacturer s recommendations for maintaining closed-ended PICCs. -Collect blood specimens from a PICC catheter using a 10-ml (or larger) syringe. -DO NOT USE VACUUM-TYPE BLOOD COLLECTION SYSTEMS. They generate extremely high pressure which can rupture PICC catheters. -After a PICC catheter has been removed, the sire should be covered with an occlusive dressing to protect it from induction to prevent air embolism. -7-
Implanted ports (e.g. PORT-A-CATCH) out of sight: General Information: The type of CVAD is totally implanted under the skin and has no external parts. It is considered a long-term CVAD and may last for 2,000 punctures. They can handle both bolus injections and continuous infusions. The ports are composed of a metal or plastic housing that surrounds a self-sealing silicone gel. A silicone catheter is attached to the port housing. An implanted port minimizes infection and may be more convenient and cosmetically appealing to active young adults. However, they also have drawbacks: they must be surgically implanted and accessing them may be painful for the individual. Insertion Information: Ports are usually inserted in the O.R or interventional radiology suite. The surgeon makes a subcutaneous pocket for the port housing, inserts the catheter into the subclavin vein, and advances it into the superior vena cava. (Depending on the therapy). The catheter can be inserted into any vein or artery, the brain, or the epidural space for pain control.) The insertion sire requires a dressing until it heals. Nursing care and use: -To access the port, first palpate the area to locate it. -Numb the area with a topical anesthetic cream, ice, or ethyl chloride spray, depending on the physicians order. -Using sterile technique, clean the area with alcohol followed by povidinge-iodine. -With the thumb and index finger of the no dominant hand, fell for the edge of the port housing and stabilize the port between the thumb and finger. -Push the Huber no coring needle through the skin and silicone gel until you hit the port s rigid back. -Confirm that the needle is correctly placed by checking for blood return, then flush with saline. -After accessing the port, cover the Huber needle with a transparent dressing and start the infusion, as per the physicians order. -Change the Huber needle and dressing every 7 days. -If an accessed port is not being used to infuse fluid, flush it daily with 5 ml of heparin (100 units/ml). -If the port is not accessed or in routine use, access and flush it every 28 days to maintain patency. -For blood drawing, use a 10-ml (or larger) syringe or a vacuum blood-collection system. Remember that may alter lab results. -8-
Troubleshooting complications: No matter what type of CVAD and individual has, it must be assessed frequently for symptoms of catheter complications or to initiate nursing interventions will compromise client care and could expose the nurse to a malpractice lawsuit. Three of the most common sources of trouble are: 1. Catheter-relates sepsis 2. Catheter Malpostition 3. Catheter Malfunction Quick tips for CVAD Assessment: -If you have any reason to believe a CVADs tip is out of position or occluded, do not attempt to use the CVAD. -Notify the physician and prepare the individual for x-ray or thrombolytic interventions, as indicated. Problem Signs and symptoms A. Catheter-related sepsis -Drainage from exit site. -Redness, pain at exit site -Fever spike B. Catheter tip in right atrium -Sudden increase in heart rate -Decrease in external catheter length C. Catheter tip in jugular vein -Individual has sudden earache on side of catheter -Individual hears bubbling in ear when catheter is flushed D. Catheter malfunction -Inability to infuse fluids though (e.g. clot formation inside catheter tip, catheter at the prescribed rate kink in catheter) -Absence of substation free-flowing blood return -Individual must be repositioned to obtain blood return -Visible collateral chest veins. Documentation: The appearance of the area around the CVAD insertion sire shall be documented by the RN every shift and after every dressing change. The following items shall be considered at each assessment and shall be included in the Q shift/post dressing change documentation: -Accidental removal -9-
-Suspected blood clot -Absence of blood return -Disconnect with blood loss -Infiltration -Suspected air or catheter embolism -Persistent pain at insertion ste or in shoulder on same side of CVAD -Infection -Burning along tunnel while flushing or during infusion -pain or ringing in ear while flushing or during infusion -Swelling/edema -Resistance to flushing or during infusion, distended veins on same side as CVAD -Bleeding at the site. -Unsecured CVAD (e.g. broken sutures) A special incident report shall be completed if any of the following conditions occur: -Accidental removal -Absence of blood return in CVAD unresolved after troubleshooting (exception: peripheral CVAD) -Disconnect with blood loss -infiltration -Failure to follow policy and/or procedure. -10-