Your Mission….
Prevention and Early Detection!!!!!
Quality Improvement
Evidence-based practice
Teamwork and Collaboration
Safety

“minimize risk of harm to patients and
providers through both system effectiveness
and individual performance”
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Indications
Long-term
Caustic meds
TPN (dextrose content > 10%)
Monitor RA pressures
Dialysis
Multiple therapies
No peripheral access
Frequent blood sampling
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What’s in a Name?
Central Venous Access Device (CVAD)
CVC
Central line
By type (percutaneous)

TLC (triple lumen catheter), PICC
By site

subclavian, jugular, femoral
By brand name (tunneled)

Broviac, Hickman, Groshong, Mediport
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What’s the Difference?
Similarities
Tip of catheter in a
“central” vein:
• Superior vena
cava
Differences
How/where it is
inserted
Length of stay
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Method 1: Percutaneous
Needle stick, through skin, directly into
vein.
Central (7 days-Phillips)
 PICC (> 7 days to several months)

Single, double, or triple lumen
Triple: proximal, medial, distal ports
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PICC line
Peripherally Inserted Central Catheter
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Tunneled
Surgical procedure
Very long-term
Exit site: chest or abdominal wall
Examples:
Hickman
 Groshong
 Implanted port (medi-port)

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CVAD Insertion
Supplies : Check P&P
tray
antiseptic solution
Dressing material
CONSENT
10 cc Syringes w/ NS
Needleless caps
“time out” check list
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Patient Teaching r/t insertion
Purpose
Position: flat, Trendelenberg
keep hands down
face covered
turn head away
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Complications of CVAD
Pneumothorax
Malposition
SVC syndrome
Occlusions
Infection
Air Embolism
Unintentional disruption
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Central Venous Catheter Complications —
Pneumothorax, Hemothorax, Chylothorax
Cause
 During insertion of CVC, introducer may
cause trauma
 Pneumothorax (collection of air in the pleural
space due to trauma to lung)
 Hemothorax (collection of blood in pleural
cavity)
 Chylothorax (transection of the thoracic duct
causes lymph fluid to enter the pleural cavity)
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Central Venous Catheter
Complications: Pneumothorax
Treatment
early detection: CXR after insertion
 Oxygen
 Monitor vital signs
 Pressure should be applied over the vein
entry site
 Remove the catheter
 Chest tube if appropriate

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Obstruction – Prevention is Key
Positive Pressure Displacement device
Flush unused ports per protocol
‘Push-Pause’ technique
Check solution for precipitates
Filter if indicated
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Flushing a CVAD
10 mL syringe or larger
Aspirate for blood return before flushing
(INS,2006)
SAS or SASH (per hospital protocol)
 Groshong Catheter – saline only
“push – pause” technique
Q 12 or 24 hours – per protocol
Positive pressure caps

flush, remove syringe, clamp
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Infection
CRBSI
Exit site infection
Catheter tract infection
Septic thrombophlebitis
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Central Venous Catheter Complications:
Catheter Related Blood Stream Infection
(CRBSI)
Cause
Bacteria or fungi in a patient who has a
intravascular device with positive blood
culture
 All BSIs that cannot reasonably be linked to
a site of local infection are attributed to CVC
 Biofilm
 Contamination

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Central Venous Catheter Complications:
CRBSI (continued)
Prevention (National Patient Safety Goals)
 Strict sterile technique
 Implementation of bundle approach
 Tunneling and subcutaneous cuffs
 Antiseptic-impregnated dressing
 Colonization-resistant polymers
 Contamination-resistant hubs
 Luminal antimicrobial flush/lock solutions
 Good hand hygiene
 Frequent site assessment
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CR-BSI “bundle”
Hand hygiene
Maximum barrier precautions

“time out” during insertion prn
Chlorhexidine gluconate site disinfection
Optimal catheter site (avoid femoral vein)
Daily review of line necessity – remove
when no longer medically indicated.
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Systemic Complication: Venous Air
Embolism (VAE)
Cause
 Allowing the solution container to run dry and
then hanging a new bag
 Loose connections that allow air to enter
system
 Poor technique in dressing and tubing
changes for central lines
 Presence of air in administration set
Factors that must be present:

direct communication with source of air

Pressure gradient
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Systemic Complication: Venous Air
Embolism (VAE)
Signs and symptoms
 Patient complains of palpitations
 Lightheadedness and weakness
 Pulmonary: dyspnea, cyanosis, tachypnea,
expiratory wheezes, cough
 Cardiovascular findings: “mill wheel”
murmur; weak, thready pulse; tachycardia;
substernal chest pain, hypotension
 Neurologic findings: change in mental status,
confusion, coma
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Systemic Complication: Venous Air
Embolism (VAE) (continued)
Prevention
 Purge all air from administration sets
 Use 0.22 micron air-eliminating filter
 Follow protocol for dressing and tubing
changes for central lines
 Attach piggyback meds to the proximal
injection port
 Use Luer-Lok connectors
 Do not bypass the “pump housing” of EIDs
 After removal of central lines initial dressing
should be occlusive
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Systemic Complication: Venous Air
Embolism (VAE) (continued)
Treatment
 Call for help and notify physician immediately
 Once VAE is suspected, any central line
procedure in progress should be stopped;
clamp line
 Place in Trendelenburg position on left side
 Administer oxygen
 Maintain systemic arterial pressure with fluid
resuscitation and vasopressors
 Monitor vital signs
 If circulatory collapse initiate CPR
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CVAD Dressing Change
Prevention of infection is dependent
upon
1.
2.
effectively reducing the number of
microorganisms on the skin
Limiting access of the microorganisms to
the catheter site.
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Discontinuing a CVAD
Only for percutaneous
Position: Trendelenburg
Valsalva maneuver during removal
Apply pressure
Pressure dressing
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Drawing blood from a central line
(Dominican procedure)
Turn off IV solutions
Flush w/10 mL NS
Withdraw 5 mL “discard”
Use syringe or vacutainer to withdraw
desired amt. blood
Flush w/ 20 mL NS
Label specimens “line draw”
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