Post on 16-Feb-2017
Vascular Access: An all encompassing approach
Disclaimer
Chesapeake Vascular Access though new in formation has over 20 years of vascular experience working for them
Our mission is to empower people to give great care through a 360 degree approach from insertion of vascular access devices to education for the care and maintenance of these devices
Objectives
Learn venous anatomy Types of Vascular access How to locate vessels in the arm Insertion of Peripheral IV’s Care and maintenance of Central lines Complications related to vascular access Legal issues related to Vascular access
Venous anatomyVenous anatomy
Three layers that make up veinThree layers that make up vein– Tunica Intima – inner layer, once cell thickTunica Intima – inner layer, once cell thick– Tunica meida- middle layer, muscle layer of the veinTunica meida- middle layer, muscle layer of the vein– Tunica externa- outer layer of connective tissueTunica externa- outer layer of connective tissue
Types of Vascular access Devices
Peripheral – Short PIV catheters- less than 3” – Midline catheters- greater than 3” tip terminating before
axillary vein Central
– Non-tunneled CVC- usually TLC dwell time recommended less than 2 weeks R/T high risk of infection
– Long term CVC- longer dwell time, lower risk of infection PICC Port-a-cath Tunneled lines
Vascular Access Devices
Valved Catheters•Closed-ended valved catheter:
Groshong®• Slit valve near distal tip of catheter• Three way pressure sensitive valve• No heparin needed• No clamp
•Open-ended valved catheter: PAS-V®, SOLO®
• Pressure sensitive valve is in hub• No heparin needed• No clamp
Short Peripheral IV catheters
Less than three inches in length and usual dwell time is @ 72hours
Placed in veins in the arm and hand Avoid areas of flexion Can be used for non-vesicant solutions
– pH between 5-9 and osmolarity between 600- 900 mmOsml
Midlines
Catheters are greater than 3” and the tip terminates before the axillary vein
Usually placed above the AC area in upper basilic vein
Are also for non-vesicant solutions– pH between 5-9 and osmolarity between
600- 900 mmOsml These catheters can dwell up to 4 weeks
but if catheter has any leaking, phlebitis, or infiltrations catheter should be removed and replaced
Require dressing changes once a week or PRN
PICC: Peripherally Inserted Central Catheter
A long term catheter that is inserted in a large vessel in upper arm and threaded through vein into distal SVC
This is a central line and is for all types of therapies Average dwell time can range from 2 weeks up to a year or
more Require dressing changes once a week or PRN Tip confirmation devices can be used with these catheters to
eliminate the chest x-ray
Non tunneled CVC
Usually short dwell time due to high infection rate
Are for all therapies Tip of catheter resides in
distal SVC unless placed femoral in which is in IVC
Not usually seen in long-term facilities
Require dressing changes once a week or PRN
Tunneled central venous catheters
Also a surgical procedure for insertion, but also needs physician to remove because of Dacron cuff
Common thread these catheters have a Dacron cuff this cuff adheres to the tissue at the entry to the tunneled area. This allows a waterproof barrier
Catheter is inserted into vessel and then tunneled under the skin. This is to reduce the risk of infection
These catheters can be inserted as CVC for ABT, or there are HD catheters. These range in sizes and manufactures
General care of all central venous devices
Dressings get changed once a week and as needed– If wet, soiled, no longer intact
Needless connectors need to be changed at least once a week some facilities change during tubing change or if blood is drawn
If catheter becomes dislodged ie. pulled partially out, do not remove. Anchor catheter to secure catheter with tegaderm film and tape and call physician and Chesapeake vascular access
If catheters become occluded call physician for order for cathflo and then call vascular access team
– This includes catheters that flush but do not draw blood.
Central line dressing changes
Supplies– A CVC dressing change kit– A Stat Lock if changing a PICC/ midline dressing– Non sterile gloves
Steps for CVC dressing changes
1) Anchor catheter to prevent pulling of catheter2) Wash hands open kit and don mask3) Wearing non-sterile gloves remove old dressing carefully as to not
dislodge catheter• Do not touch insertion site with non-sterile gloves
4) Once old dressing removed discard soiled gloves and don sterile gloves inspect site for CVC complications
5) If there is a Stat lock remove using alcohol carefully as not to dislodge catheter
6) Cleanse area with chlorhexidine gluconate solution use scrubbing back and forth action for 30seconds
7) Allow solution to dry for 2 min do not fan area8) Once dry cleanse area with skin prep found in Stat lock packet and once
this dries apply Stat lock • This of course is omitted if catheter is sutured in place
9) Apply tegaderm dressing and date and time dressing
Practice Dressing change
Port-a-Cath
A surgically placed central venous device for the administration of long term intermittent vascular needs
When not in use catheter gets accessed once a month for maintenance
When in use port needle gets changed with each dressing change once every 7 days
This catheter is used a lot in cancer patients but can also be for difficult access patients
Port-a-cath access and care
Port needles are specially designed for port devices. These needles are a 90 degree angle needle
It is important to hold needle on insertion straight to prevent coring of the needle
Prior to access or re-access apply ice to site to help decrease pain during insertion
Supplies– Port access needle– Central line dressing change kit– Extra sterile gloves– Sterile flush solution– Needleless connector
Port-a-Cath access
Wash hands Open kit and place all sterile items together Don mask and if catheter accessed already apply non-sterile gloves and
carefully remove dressing so as to expose port needle do not pull out yet Apply first pair of sterile gloves and grasp port needle firmly along with
anchoring of skin and gently pull port needle out – Be careful as this needle can sometimes bounce back and stick you or patient
Discard old needle and gloves in appropriate receptacles Apply new pair of sterile gloves and cleanse skin with chlorhexidine gluconate
solution using back and forth motion for 30sec and allow to dry 2 min While skin drying pre flush new port needle and the with non dominate hand
grasp port with thumb and second finger locating center with forefinger– Remember is skin was already access do not reinsert in same hole can cause tissue
necrosis With dominate hand grasping 90 degree port needle insert needle straight
down. You should feel bottom– To prevent coring of port needle
Apply tegaderm and anchor catheter to prevent twisting of catheter
Practice Port-a-cath
Pearls of wisdom for Port-a-caths
Do not twirl port this pulls catheter out of position Grasp catheter firmly when removing and be careful
for reflexive action to prevent needle injury Only use specifically designed needles for ports to
prevent coring There are different size needles from ½”, 1”, 1 ½”
port needles for different depths of ports Do not over push port needle as it can damage the
bevel of the needle and cause burrs which can damage the port
No gauze under dressing
Blood sampling from CVC
Supplies for transfer sampling– Blood tubes required for specific specimens– 2- 10 ml saline flush syringes– 2- 10ml sterile syringes– Vacutainer with blood safety transfer device
Supplies for direct sampling•Blood tubes required for specific specimens
•2- 10ml saline flush syringes
•Vacutainer with normal hub
Blood drawing pearls
Always stop all infusions at least 1 minute prior to drawing blood sample
Always draw waste of 5-10ml prior to drawing blood sample unless drawing blood cultures in which first blood is recommended
Always change needleless connectors after blood draws
Always flush well after blood draw 10-20ml of normal saline
Demonstration of Blood Drawing techniques from CVC
Complications related to CVC devices
Infiltration- Inadvertent administration of a non-vesicant solution/ medication into the surrounding tissue
Extravasation- The Inadvertent administration of a vesicant solution/ medication into surrounding tissue
Phlebitis- Inflammation of the vein, that begins at the tunica Intima can lead to Induration and thrombus
SVC syndrome- is a group of symptoms caused by obstruction of the superior vena cava
Thrombus- a clot anywhere along the catheter within the vessel Occlusions- something occluding the catheter usually a clot
within the catheter Persistent withdrawal occlusions-Usually cause by a fibrin
sheath surrounding the catheter in which the catheter can flush but not draw blood.
Infiltration/ Extravasations of CVC
This can happen although rare. Can be caused by a catheter that has been pulled
out of the blood vessel enough to cause leakage into surrounding tissues or a breakage of catheter
Stop infusion and call physician and pharmacy– Some medications interact when heat or ice is applied so
wait for instructions– Also consult with pharmacy as to treatment
Do not remove catheter because some medications have counter agents
Phlebitis
Phlebitis is very rare Phlebitis of a CVC usually manifest itself as
chest pain every time there infusion is on Can happen if patient lost an enormous
amount of weight the vessels are no longer stretched and tend to fold on themselves
If this happens inform Dr so a work up of the catheter can be made
SVC syndrome
Symptoms include– Dyspnea– Headache– Facial edema– Venous distention in the neck and distended veins in the
upper chest and arms– Upper limb edema – Lightheadedness– Cough– Edema of the neck, called the collar of Stokes
This requires immediate follow up or will get worse
Thrombus
Thrombus can happen anywhere along the catheter within the vein
Can be a partial or full occlusion Signs/ Symptoms
– Swelling in fingers and works way up arm– Pain in neck– Discoloration of arm
Catheter needs to be evaluated by health care team these lines can sometimes be salvaged under certain circumstances
Occlusions and Persistent withdrawal occlusions
These are occlusions within the catheter can be cause by a clot or by a precipitate
Precipitate- Is when two totally incompatible medication are infused through catheter and cause a crystal cascade affect the only treatment for this is changing line
Clots- When catheter has not been adequately flushed can cause a clot to form
Cathflo can treat both and occlusion caused by a clot and persistent withdrawal occlusion
Cathflo requires an order from the Dr and then when medication arrives call Chesapeake Vascular access
Peripheral IV’s
Peripheral IV Insertion
Veins of the arm– Cephalic vein– Basilic vein– Medial veins– Accessory cephalic
Veins of hand– Metacarpals– Dorsal venous arch
Choosing the Right Vessel
The veins should be palpable, soft, resilient The veins should be @ 1” in length and
without bifurcations Golden Rule of IV TherapyGolden Rule of IV Therapy
Smallest Gauge device possible in Smallest Gauge device possible in the Largest vein possible to the Largest vein possible to
accommodate the prescribed accommodate the prescribed therapytherapy
The Larger the device the higher the risk for Mechanical phlebitis
Choosing the right Catheter
What is going to infuse?– pH of medication
PIV’s and midlines pH needs to be 5-9 CVC no restriction on pH
– Osmolarity of medication Osmolarity for PIV and midlines needs to be 600-900 mmOsml CVC no restriction on osmolarity
How long is this medication going to infuse? – PIV are good for @ 3 days– Midlines are good for 4 weeks– CVC are good for long term therapy
The condition of the patients veins– If the patient already has occlusions in the veins then a PICC is not
appropriate catheter
Peripheral Insertion Overview
Locate vein Prepare site and wash hands Insert needle bevel up at 0-15 degree angle,
insert till you receive flash and then level needle
Insert needle a little bit more Then thread catheter release safety Add 6” extension tubing Secure and document
Practice locating veins and insertions
Most Common Complications of PIV insertions
Infiltration- Inadvertent administration of a non-vesicant solution/ medication into the surrounding tissue
Extravasation- The Inadvertent administration of a vesicant solution/ medication into surrounding tissue
Phlebitis- Inflammation of the vein, that begins at the tunica Intima can lead to Induration and thrombus
Documentation of complications
Time and occurrence Identify drug and solution IV device removal and patient comments Unusual occurrences report should be filed Document what you see and interventions (do
not document that you filed an incident report in chart)
An incident report must be filled out when An incident report must be filled out when there is any IV complicationsthere is any IV complications
Before and After the IV
Complications continue
Compartment syndrome caused by an IV
After one week
Legal Implications related to Vascular access
Malpractice- negligence resulting from a prudent professional nurse would do
Assault and Battery- Placing a PIV or CVC without proper consent– PIV requires verbal permission– CVC and midlines require written permission
How to prevent complications for PIV and CVC
Monitor IV site closely every 2-4 hours Flush catheter well and often to maintain
catheter patency Keep dressings dry and intact. Secure tubing
to help prevent pulling on catheter For PICC’s make sure Stat Lock is changed
every 7 days with dressing changes to prevent catheter movement or dislodgement