Vascular Access at MUSC
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Transcript Vascular Access at MUSC
Vascular Access at MUSC
Lynn Williams, RN
Vascular Access Resource Nurse
Specialty Nursing Department
Vascular Access Devices
2013
Objectives:
•Intro to Infusion Nursing Society (INS)
•Identify common types of venous access
devices, inc general characteristics
•Discuss device selection & placement
departments
•Review assessment, care and management of
central venous access devices – C75 Central
Venous Catheter Policy
•Identify potential complications and related
interventions regarding a central venous access
device
Infusion Nursing Society
(INS)
Recognized as the global authority in
infusion nursing, dedicated to exceeding
the public’s expectations of excellence by
setting the standard for infusion care.
The Standards of Practice are written to
be applicable in all patient settings &
address all patient populations.
Be advised – the “Standards” is a legally
recognized document.
General Characteristics of CVAD
Catheter Materials
Polyurethane, Silicone, Impregnated, FDA approved for Power
injection of IV contrast during radiological imaging
French Sizes
1.2 fr – 15 fr
Lumens
Single, double, triple, & quad available
*Golden rule – Less is more!
Cuffed vs non-cuffed
Valves
Internal (tip) – Groshong
External (hub) – PASV, Solo Power PICC
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Choosing the Best VAD
for Each Patient
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Diagnosis
Prescribed therapy
Duration of therapy
Physical assessment
Patient health history
Support system/resources
– Case Managers
• Patient preference
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List of drugs that d/t pH, osmolality or chemical
structure, cause frequent IV restarts
• Amphotericin-irritant
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• Bactrim - pH 10.0
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• Calcium Gluconate –
Hypertonic
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• Chemo Vesicants- pH
• Ciprofloxacin – pH 3.3 •
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• Dilantin – pH 12.0
• Dobutamine – pH 2.5
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• Erthromycin – irritant
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• Morphine(PCA) – pH 2.5
All Penicillins – pH
10/hypertonic
Phenergan – pH 4.0
Potassium >20 KCL –
Hypertonic
PPN/TPN – Hypertonic
Rocephin –
Irritant/hypertonic
Tobramycin – pH 3.0
Vancomycin – pH 2.4
Selection of Catheters and Sites
CDC Recommendations
Catheters & Site selection
PIV vs PICC: Use a peripherally inserted
central catheter (PICC) when the duration
of IV Therapy will likely exceed six days
Weigh the risks/benefits of placing a
central venous device (CVD) at a
recommended site to reduce infectious vs
mechanical complications (IJ vs Subcl vs
femoral)
Catheter & Site Selection cont’d
Choose a device with the minimum # of
lumens/chambers essential for treatment
Promptly remove catheters that are no
longer essential
Central Venous Access
Devices
• Peripherally Inserted Central Catheters
(PICC)
– Regular & cuffed/tunneled
• Non-tunneled/Non-cuffed Central Catheters
• Tunneled/Cuffed Central Catheters
• Implanted Ports – regular vs power
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Departments that Place &/or Manage CVAD’s
• VAIN Team
– Bedside PICC & difficult PIV insertion
– Screen all Adult IP PICC orders
– Adults
• Interventional Radiology Dept.
– Place all types of venous access devices
– All ages
• Infectious Disease PICC Service
– Place both cuffed & regular PICCs
– Bronch Lab, EP, Cath Lab
– Adults
• OR/Surgeons
– All ages
– All devices EXCEPT PICCs
• Pediatric Services
– Procedural area on 5th floor of CH – PICCs
– Bedside PICCs by specialized RNs in ICUs
Peripherally Inserted Central Catheters
PICCs
• Usually inserted using a vein in upper arm
• Can be used for most IV therapies and to
obtain blood draws
• Select for pt’s requiring IV abx’s, TPN,
poor IV access needing frequent blood
draws
• Easily removed either at bedside while an
IP or by a Home Health Nurse after
discharge
• FYI – if pt has no insurance, they are
unable to have device cared for at home
Adult PICC White Board
• All Adult PICC orders go to the VAIN team
for evaluation and dept assignment for
device insertion
• White Board provides info r/t which dept is
assigned to insert PICC w/ comments
• Certain criteria dictate which dept is best
suited to place the PICC: occlusion
history, sedation, complicated diagnosis
• Found on the Intranet
PICCs Placed at MUSC
BARD Power PICC
(polyurethane)
Cook Silastic
PICCs
Cook Spectrum
(polyurethane,
Abx impregnated)
Centrally Inserted Catheter
• Non-Tunneled CVC (no cuff)
– Short term, Acute care, percutaneous catheters
– Typically used for days – weeks for all types of
IV therapy, blood draws, monitor central venous
pressure in ICUs
– Example: PICCs, Acute single/dual/triple/Quad
CVCs, Dialysis/aPheresis catheters
• Tunneled CVC (cuffed)
– Long term therapies – TPN, chemo
• Oncology, Cardiac, GI patients
– Dacron cuff provides catheter stability and
serves as a barrier to prevent infection
– Examples: Cuffed PICCs, Chronic
Dialysis/aPheresis catheters, Hickman, Broviac,
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Tunneled
IJ entry site
Subcutaneous
Tunnel w/
cuff
Non-tunneled
IJ entry site
No subcutaneous
Tunnel or cuff
Implantable Ports
Implantable Ports
Implanted Ports
- Plastic, stainless steel or titanium
housing attached to a catheter
implanted under the skin
- Chest, Arm, Thigh, Abdomen
- Completely under skin – swimming
permitted when not accessed once
the incision has totally healed
- Requires special non-coring
needles to access
- Available as power injectable
- Can remain in place for years
- Sickle cell, Oncology, Rheumatoid
Arthritis, intermittent long term tx’s
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Identifying Power Ports
• Prior to a fluoroscopic exam requiring
power injection of contrast:
– Clinical staff (radiology techs, RNs) will
positively ID device
• Manufacturers ID card, arm bracelet, key tag
• Manufacturers sticker found on IR/OR document
• Image – view “CT” marker on port chamber
– Radiologist to review prior image before being used
– If no prior image, an image of the appropriate
anatomic area will be done & reviewed by Radiologist
• Radiology Dept. has a process they follow
to confirm if a device is power injectable.
Port Needle
Sets
Before Meds can be administered
via CVAD:
• Verify tip location using fluoroscopy
– For newly placed devices
– Transferred patients with an indwelling central
venous catheter
– If there is a known or questionable change in
catheter position
• Migration or dislodgement suspected
• Securement device has become dislodged
• S/S: No blood return &/or unable to flush
If no blood return, device is not to be used until
evaluated/treated for clot/thrombus or mechanical
issues!
IV Flush Orders
• Practitioner must write order for heparin flushes
• Standard Adult and Pediatric flush orders
• Each device has a standard flushing protocol
including 0.9% sodium chloride and heparin
• If heparin is contraindicated, consider
alternative, such as argatroban or tPA
• When patient is admitted with a device, initiate
the order for RN to get heparin
Dialysis/aPheresis catheters
• Locked with high-dose heparin
– Refer to IV Flush Orders
– Adults: Use 1000u/ml heparin
– Pediatrics: Use 100u/ml heparin
• May only be accessed by nurses trained to
do so (ICU, aPheresis & Dialysis RNs)
• Renal service must be consulted before
using catheter. If no longer being used for
aPheresis &/or dialysis, the Renal MD
MUST transfer care to RNs on unit.
Post-Insertion Complications
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Catheter Dislodgement
Catheter Migration
Air Embolism
Catheter-related Bloodstream
Infection
• Venous Thrombosis
• Catheter Occlusion
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Catheter Dislodgement
• Stabilization devices (Statlock, sutures,
securement dressings) are used to prevent
catheter from falling out, catheter tip
malposition, and migration of bacteria
• If displacement is suspected, CXR is
required to verify tip placement
• S/S of dislodgement – catheter
malfunctioning, securement device lose,
device is semi-pulled out
• Do not try to re-insert the device
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Catheter Migration
• Tip can spontaneously migrate into right
atrium or internal jugular
• May result from coughing, ventilator, forceful
flushing, heavy lifting, hypertension
• S/S = Inability to flush, infuse or aspirate
• “Ear gurgling” or “running stream” while
catheter is being flushed
• Get a chest x-ray
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Catheter Tip Malposition
Catheter tip
right jugular
Catheter Related Bloodstream
Infections (CRBSI)
During CVC insertion – use maximal sterile
barrier precautions:
Cap, mask, sterile gown, sterile gloves, sterile
full body drape
Put mask on if removing a dressing to
inspect a site
Prep skin using Chlorhexidine gluconate w/
alcohol – allow to dry!!
Assess catheter necessity daily!
Venous Thrombosis
• Diagnosed via Vascular Ultrasound
• What do you do??
– Before removal, consider this:
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Is the catheter functioning normally?
Are symptoms manageable?
Can patient receive anticoagulant treatment?
Does patient have known occluded vessels that will
compromise a new device plcmt in the future?
• Consider patients condition, long term
treatment and the need for the existing device
Occlusion Management
• Partial Occlusion: device flushes, no
blood return
• Total Occlusion: No flush or aspiration via
device
• Both types of occlusions can safely be
treated with Cathflo Activase (alteplase)
– If mechanical malfunction has been ruled out,
order Cathflo for catheter occlusion
– Follow Occlusion Management guidelines
(Appendix B in C75 Policy)
Device Removal
• RNs have to demonstrate competency to
remove a non-tunneled catheter.
– RN competency is based on skill & frequency
of performance
• ONLY dialysis or ICU RNs w/
demonstrated competency may remove
large bore catheters (dialysis/aphersis)
• ONLY MDs and non-surgical specialist
that are credentialed may remove cuffed
devices, including PICCs.
Air embolism = entry of a bolus of air into
the vascular system; can occur during
placement or after device removal
Reduce the risk of embolism:
• Place the patient in Trendelenberg position
to increase intrathoracic pressure, unless
not tolerated or contraindicated
• Have patient hold breath and gently bear
down (Valsalva).
• Sx’s & Sx’s include: palpitations, resp
distress, hypotension, arrhythmias,
Non healing site over port!
Post port plcmt – bruising!
Extravasation
CDC Recommendations
Educate/training clinicians who insert/maintain
cath’s – *SIM Lab program being developed
Use maximal sterile barrier precautions
Use >0.5% chlorhexidine skin prep w/ alcohol
(ChloraPrep = 2% = isopropyl alcohol)
Avoid routine replcmt of CVCs as strategy to
prevent infection
Periodically assess knowledge of &
adherence to guidelines
Central Venous Catheter Policy
• Owner: Central Venous Access Committee
– Multidisciplinary team
• Purpose: Provide guidelines for the insertion & care
of all VADs
• For all staff that handle or insert a Central VAD
• Includes:
– 8 Appendix Included: References, VAD Occlusion Mgmt,
IV Flush Orders (Peds/Adults), CVL Guideline, Ethanol
Lock Info Sheet, VAIN Team Guidelines
Questions???
Lynn Williams, RN
Vascular Access Resource Nurse
792-1143
11109