Mary Lou Garey MSN EMT-P MedFlight of Ohio

Function Prolonged and frequent access to venous circulation Allows for patient to carry on normal life; decrease number of needle sticks Medications, parenteral nutrition, and blood transfusions can be administered

Function Inserted in central circulation where they remain for weeks or months Allows patients to be managed at home Can provide immediate venous access

Function Many types are in use. They consist of three catagories Central venous catheters (CVC) Implanted ports Peripherally inserted central catheters (PICC)

Description Most are constructed of radiopaque silicone Location of catheter will vary on patient patient preference, type and duration of therapy, and self / home care capabilities

The venous catheter is inserted with the tip in the superior vena cava just above the right atrium, thus the name of central venous catheter

Devices and insertion techniques Peripherally Inserted Central Catheters (PICC Lines) Subcutaneous Ports / Infusion Ports / Med Ports Hickman and Broviac Catheter

Peripherally Inserted Central Catheter Inserted through large peripheral veins

Best Suited for treatments lasting from several weeks to 6 months requiring frequent access to veins

Pros The least invasive of all the central lines Easily inserted and removed Relatively inexpensive Complications are usually minor Cons High maintenance (daily flushing) Often migrates Limits lifestyle somewhat Limited time frame of use

Insertion Sterile technique Bedside ultrasound insertion by a PICC RN Interventional radiology procedure using fluoroscopy or ultrasound

Ultrasound Insertion

Insertion Needle is inserted through a deep vein in the arm A wire is placed through the needle A dilator sheath is placed over the wire The catheter is threaded through the sheath

Insertion Chest X-rays are used to confirm that the tip is in the superior vena cava (SVC) just above the heart

Open end PICC lines Saline or Heparin used to keep line from clotting Closed end PICC lines (Groshong) Saline flush is all that is required to keep line from clotting

Care of the PICC Dressings changes by home health Rigorous arm activity discouraged PICC is flushed with saline or heparin / saline every day

Accessing a PICC line Flush with 10cc Normal Saline Aspirate for blood return

Always use a 10cc syringe If you meet resistance NEVER FORCE A FLUSH Re-attach flush to device and try a second time

Also known as MedPorts or infusion ports Plastic or titanium housing placed under the skin and connected to the vein via a tube. The port is a silicone disk that can withstand 2000 punctures

They can be single or double lumen

Pros Least maintenance Good for long term access (>6 months) Good for monthly chemotherapy Cons Most costly device Most time consuming to implant and explant

Insertion General anesthesia A pocket is made in the skin for the port A tunnel is made to connect the chest port to the tubing. Tubing is inserted into jugular to SVC

Insertion The port is then sutured or glued into the pocket and the skin incision is closed

Care Dressing is worn for one week Is not used for 48 72 hours after insertion to minimize an infected blood clot Flush monthly and after each use with saline and heparin

Accessing a port A Huber Needle must always be used to access ports

Hickman Catheters Broviac Catheters Groshong Catheters It s only a name. they are all tunneled catheters. Groshong will not have clamps

A tunneled external catheter Single or duel lumen Used for Intermediate to long term use Frequent access High flow infusion and or infusion of blood products

Insertion General anesthesia Tunneled insertion of line The catheter is secured by glue or later the patient s own tissue growth The tip ends at the distal SVC above atrium

Broviac Catheter Cuff / Exit Sites

Accessing Aseptic technique Unclamp port being used (if not a Groshong product) Flush with 10cc saline Check for blood return Leurlock IV line into port

Caution Air emboli use the clamps on the catheter Thrombus Catheter shearing

Site Infection Pain Erythemia Swelling Drainage

Sepsis Elevated temp Tachycardia Weakness Body Aches Septic Shock

Thrombosis Sluggish fluid flow Swelling Local Tenderness Ecchymosis

Torn or leaking catheter Fluid extravasation Burning Local Tenderness Fluid Leaking Swelling

Air Embolysm Chest pain Shortness of breath Change in level of responsiveness Neurological deficit

Short line with two ports Placed in the femoral, subclavian, or internal jugular veins Used for temporary dialysis access

Caution High risk of emboli Must always aspirate prior any use Extremely high risk access site! Dialysis catheters are rarely accessed outside of the dialysis unit

Both ports end in same vessel Open ended catheters Instilled with high concentration heparin or a citrate solution after each dialysis to maintain patency Never flushed, but dwelling contents aspirated prior to use

Indications Cardiac Arrest Respiratory Compromise Hemodynamic Instability Bridge to Central Line Altered Level of Consciousness Difficult IV Placement

AHA; NAEMSP Guidelines IO should be considered early in vascular access emergencies ET tube is no longer recommended for drug delivery Central lines are discouraged

With pressure flow rates are similar to IV Tibial - 18 ga Humeral -16 ga

Contraindications Local Infection at insertion site Fractures in bone to be used Recent (24 hour) IO in same extremity Absence of anatomical landmarks or excessive tissue

Atropine Valium Digoxin Nitroglycerine Dopamine Dobutamine Amiodarone Phenergan