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
4
Choosing the Best VAD
for Each Patient
•
•
•
•
•
•
Diagnosis
Prescribed therapy
Duration of therapy
Physical assessment
Patient health history
Support system/resources
– Case Managers
• Patient preference
5
List of drugs that d/t pH, osmolality or chemical
structure, cause frequent IV restarts
• Amphotericin-irritant
•
• Bactrim - pH 10.0
•
• Calcium Gluconate –
Hypertonic
•
• Chemo Vesicants- pH
• Ciprofloxacin – pH 3.3 •
•
• Dilantin – pH 12.0
• Dobutamine – pH 2.5
•
• Erthromycin – irritant
•
• 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
10
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,
18
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
21
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
•
•
•
•
Catheter Dislodgement
Catheter Migration
Air Embolism
Catheter-related Bloodstream
Infection
• Venous Thrombosis
• Catheter Occlusion
28
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
29
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
30
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:
•
•
•
•
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