Beruflich Dokumente
Kultur Dokumente
In Adult Patients
TABLE OF CONTENTS
INTRODUCTION ....................................................................................................3
WHAT IS A CENTRAL VENOUS CATHETER?....................................................................5
INDICATIONS FOR USE ......................................................................................................................... 5
WHERE ARE CVCS INSERTED? .................................................................................................................. 6
REFERENCES ...................................................................................................... 67
APPENDICES....................................................................................................... 70
APPENDIX
APPENDIX
APPENDIX
APPENDIX
INTRODUCTION
The use of Central Venous Catheters (CVCs) has increased dramatically over recent years.
Once seen only in critical care areas, these catheters are now commonplace in the
medical/surgical and community environment. Depending on the patients needs, there are a
variety of central lines available. A CVC can be inserted for short-term or long-term I.V.
therapy.
Central Venous Catheter management requires evidence-based, best practice standards to
minimize complications and maximize patient outcomes. CVC management is a specialized skill
performed by IV practitioners who have demonstrated the required competencies.
PURPOSE
This self-learning module will provide you:
Information about CVCs
Information about nursing care and management of CVCs in the adult patient
This self-learning module along with return skill demonstration will assist you in meeting the
competencies of CVC management.
Please see Appendix A (Responsibility for CVC management)
LEARNING INSTRUCTIONS
The learning activities in this self-learning module are based on the objectives and will help
you to understand and apply what you have learned. It is recommended that you complete the
learning activity after each section.
If you are using this self-learning module for the purpose of review, you
may wish to attempt the learning activities first to find out what
material you need to review.
OBJECTIVES
Upon completion of this module the learner will be able to:
Define central venous catheters
Identify types of CVCs and indications for use
Describe the nursing care and maintenance of CVCs
Describe and identify complications associated with CVCs
Identify common insertion sites
Describe the difference between open-ended and closed-ended (valved) catheters
Identify the nursing responsibilities for pre-insertion, insertion and post-insertion for
percutaneous, tunneled and implantable CVCs.
List advantages and disadvantages for a percutaneous, tunneled and implanted CVC.
List possible complications of CVCs and the nursing actions for each complication.
List safety considerations when caring for a patient with a CVC, and provide the
rationale
The Arm
>
>
>
Brachial vein
Cephalic vein
Basilic vein
The Groin
>
Femoral vein
Types of
Central Venous
Catheters
Short Term
Long Term
Tunneled Catheters
Long Term
Long Term
COMPOSITION
Polyurethane or Silicone
COATINGS
May have antimicrobial or antiseptic coating to protect against bacterial seeding
May have heparin coating to reduce fibrin formation
Radiopaque to confirm tip placement by X-ray
Single, double and triple lumen catheters are available in all catheter types
Each lumen must be treated as a separate catheter
Incompatible medications can be infused simultaneously via separate lumens
Exit ports are approximately 2cms apart on the short-term catheter
Closed-ended
A valve is present at the tip of the catheter (eg. Groshong) or at the hub of the
catheter (eg. PAS-V)
Clamping is not required as the valve is closed except during infusion or aspiration
May be present on Tunneled Catheters, Implanted Ports and PICCs
10
a
b, c
a, c, d
all of the above
Answers
1) C
2) F
3) Short Term, PICC, Tunneled, and IVAD
4) True
5) Not, Closed
12
Short-Term
Catheters
13
Short-Term Catheters
A short-term catheter is inserted directly into a large central vein through the skin. These
catheters may be single or multi lumen. Some are sutured in place at the insertion site.
Examples of Short-Term Catheters:
14
b) Triple lumen
Cross-section
Proximal Lumen
Medial Lumen
Distal Lumen
USES
SHORT-TERM
OPEN-ENDED
CATHETERS
ADVANTAGES
All types of
therapies can be
administered
Preserves
peripheral veins
Can be single,
double, or triple
lumen
Adult or pediatric
sizes
Can be used for
blood sampling
Economic, quick
placement
DISADVANTAGES
PROXIMAL
18 gauge
MEDIAL
18 gauge
DISTAL
16 gauge
SIDEARM
SINGLE LUMEN
(CVP)
IV Fluid
Administration
X3
Blood or Colloid
Administration
X3
Rapid IV/Blood
Replacement
T.P.N.
X1
X1
or
X2
Medication
Administration
X3
X3
X3
Blood Sampling
X3
CVP Monitoring
W
ICH H
UB D
O Y
OU S
CRUB?
WH
HICH
HUB
DO
YOU
SCRUB?
16
HEMODIALYSIS CATHETERS
A hemodialysis catheter is a type of Central Venous Catheter used for patients requiring
hemodialysis. The lumens of these catheters are larger allowing for large volumes of blood
to be processed and returned to the patient.
The Renal Program has specific policies and procedures related to these catheters.
HD lines may be accessed by Critical Care Nurses in a Code or Trauma situation
HD lines are central catheters/ Maintain aseptic technique as they are the patients
life lines.
Catheter ports must never be left unattended and open to air.
If there are problems with withdrawing from a lumen do not push locking agent or clot
into the patient.
Once patient stabilizes please plan for use of an alternative access.
The line can be used for:
o blood samples
o infusing a medication
o IV infusion
Procedure:
Place patient supine
Create a sterile field/ Don sterile gloves/mask
Ensure both clamps closed
Clean Tego connector hub with alcohol swab and
leave to dry
Attach a 10 mL luer syringe, unclamp and withdraw 5 mL locking agent, and discard
Using a second 10 mL syringe withdraw and instill blood 2-3 times (ensures locking agent is
cleared)
Flush line with the NaCL 0.9% 10 mL pre-filled syringe for a total of 20 mL per lumen.
Infusing Medication/IV infusion
Notify the Renal Unit that the dialysis line has been accessed.
A Renal Nurse must flush and re-cap the catheter after the
dialysis line has been accessed.
17
NURSING CARE:
PRE/POST INSERTION OF SHORT-TERM CATHETERS
Short term CVCs may be inserted on
the Nursing Unit, in Medical Imaging
under fluoroscopy, in the Operating
Room, or Emergency. As a Nurse, you
may be asked to assist the Physician
with insertion.
Prior to insertion ensure the patient/family understands the procedure, its benefits and what
might be expected of the patient during and after insertion (Physician responsibility)
Perform a respiratory assessment including breathing patterns, depth, symmetry, and sounds
Place patient in Trendelenberg position to dilate the veins and reduce the risk of air embolism
if tolerated. Some patients are unable to tolerate this position. When this occurs follow the
Physicians direction.
The patient is covered from head to toe with a sterile drape with a small opening for the
insertion site (to observe/monitor the patients head area, consider placing a mayo stand
under the drape in this area).
The inserting practitioner must remove jewellery, wear eye protection, hand wash to remove
visible dirt (soap and water or 2% Chlorhexidine), subsequent hand washing before and after
palpating catheter insertion site (alcohol gel is sufficient), and use a surgical cap (bouffant
cap), mask, sterile gown, and sterile gloves.
The assisting practitioner must hand wash and use a surgical cap (bouffant cap), mask, sterile
gown, and sterile gloves.
Other personnel, such as those without direct contact, must wear a mask.
18
Post-insertion
o
o
Order a portable chest x-ray for Physician to confirm correct placement of line
FEMORAL SITE: If a Short-term CVC is inserted into a femoral site no chest x-ray
required. To confirm correct placement in vein, draw blood gas from the femoral CVC and
send sample to Lab to ensure the results are a venous sample (Venous Blood Gases). In
Critical Care areas, transduce the femoral CVC and ensure you have an appropriate CVP
waveform.
Ensure that all lumens are flushed with 20 mL of NS immediately after insertion.
Documentation
Documentation to be done on the Central Venous Catheter Insertion and Removal Form (see
Appendix B) including:
19
the _____________________.
2.
3.
4.
5.
6.
7.
20
Answers
1. directly, vein, skin
2. highest
3. open
4. Trendelenberg
5.
-
Order a portable chest x-ray for physician to confirm correct placement of line.
Document
6. Q30min x 2
7.
a)
b)
c)
d)
Subcutaneous emphysema
Bleeding
Air embolus
Pneumothorax
21
22
Peripherally
Inserted
Central
Catheters
23
Venous access is obtained by puncturing the brachial, cephalic, or basilic vein just
above or below the antecubital fossa.
The tip rests in the superior vena cava at the cavo-atrial junction.
The catheters are approximately 40-60 cm long, but may be individually sized upon
insertion.
PICCs are chosen for patients requiring IV therapy for more than six days and up to
one year.
24
USES
Peripherally
Inserted
Central
Catheter
ADVANTAGES
DISADVANTAGES
Requires a dressing
& frequent
assessments
External device
Some PICCs (small
gauge) not
recommended for
blood sampling
Not ideal for rapid
infusions
Not recommended
route for some
medications
(i.e.phenytoin).
Check Parenteral
Drug Therapy
Manual prior to use
PRE-INSERTION
Administer a sedative prn as ordered prior to the pre-scheduled procedure time
Ensure the order entry for chest x-ray for PICC tip position has been placed into MediTech Order Entry
Ensure the patient is in Ambulatory/General Day Care department 15 minutes prior to
scheduled time (if applicable)
Insertion
Insertion of PICC catheters is done by Advanced Competency Assessed RNs who have
received special training. These RNs are usually located in the Ambulatory/General
Daycare department and/or are a Home/Community IV RN
Post-Insertion
Prior to using the PICC catheter :
Ensure placement has been confirmed by x-ray
Ensure order had been received from the physician
May apply warm compress to arm above PICC venipuncture site QID x 20 minutes for 3
days PRN (to prevent mechanical phlebitis)
Do not take blood pressures or venipuncture the arm with a PICC or PAS-V port inserted.
Monitor for swelling, tenderness
Q1hr: Monitor site patency and rate of IV infusion
26
Answers
1. six days and up to one year
2. C
3. PICCs are inserted by Home IV RN, Can remain in place for several weeks/ months, easily
removed by the Competency Assessed RN, PICCs eliminate the risks associated with neck,
chest & femoral insertion, lower rates of infection, the external portion can be repaired.
4. Requires a dressing & frequent assessments, external device, some PICCs (small gauge)
not recommended for blood sampling, difficult for self-care
5. 40-60 cm long
6. sedative
7. x-ray
8. QID X 20 minutes
9
a. blood pressure
b. venipuncture
27
28
TUNNELED
CATHETERS
29
Tunneled Catheters
A tunneled catheter is a long-term catheter (lasting months to years) that exits the skin
via a subcutaneous tunnel.
A Dacron cuff on the tunneled portion of the catheter facilitates anchoring of the
catheter through granulation and acts as a barrier to infection.
Tunneled catheters may be single, double, or triple lumen.
Examples of Tunneled Catheters are Hickmans, Broviac and permanent hemodialysis
catheters (eg. Perm-Cath).
CUFFS
USES
Tunneled
Catheters
ADVANTAGES
DISADVANTAGES
Inserted in the OR
or Medical Imaging
under Fluoroscopy
Requires a dressing &
frequent
assessments
External device
Physician must
remove
30
PRE-INSERTION
Ensure patient/family understands reasons for insertion, benefits and risk of procedure.
If possible, provide an opportunity for the patient to see pictures, and handle a demo
catheter.
Discuss feelings about potential body image changes (external device).
Perform baseline vital sign assessment.
INSERTION PROCEDURE
CATHETERS
32
33
ANSWERS
1. F, single, double, or triple
2. Hickman, Broviac and permanent hemodialysis catheters (eg. PermCath)
3. Used for long-term intermittent or continuous access for medication administration,
parenteral nutrition, blood/blood product administration and sampling, hemodialysis.
4. The patient is placed in Trendelenberg position to dilate the veins and to reduce the risk
of air embolism.
5. Subcutaneous emphysema, bleeding, air embolus, pneumothorax
6. T
34
IMPLANTABLE
VENOUS
ACCESS
DEVICE
(IVAD)
35
The surgical technique to place an IVAD is similar to that used to place a tunneled
catheter. This procedure is done in the Operating Room or Interventional Radiology.
IVAD Components
36
Thoracic Placement
Peripheral Placement
37
Non-Coring Needle
USES
Implantable
Venous
Access
Devices
ADVANTAGES
Internal device, no
dressing or site care
Can be permanent
Unrestricted activity
Decreased risk of
infection
No external
components to break
Less body image impact
May be used as long as
the device is required,
functional, and is not a
source of sepsis.
DISADVANTAGES
Needle access is
required
Surgical procedure
required to
insert/remove
38
> Advise the patient to carry identification of the port model and composition with them
at all times. The implantable ports can cause minor distortion of the MRI and other x-ray
procedures.
INSERTION
IVADs are inserted in the OR/MI under a local anesthetic and sterile technique.
A cut down method is used and the catheter is introduced through a venotomy into the
subclavian, cephalic, or jugular veins.
The catheter is then positioned with the distal end positioned at the junction of the
superior vena cava and the right atrium.
The portal body is placed over a bony prominence (e.g. ribcage), to ensure easy palpation.
Appropriate site selection is essential.
Once the site is selected, the portal body is sutured to the fascia on all 4 sides with nonabsorbable sutures. This is to prevent it from twisting or moving.
The port is flushed in the OR/MI. If early access is required, it is recommended that it
be done in the OR. Otherwise, access occurs in approximately one week.
The entire procedure takes 30-60 minutes.
Slight edema and tenderness around the port implantation site is normal for the
first few days post operatively and does not prevent use unless it is excessive
Most Physicians prefer to wait a few days before accessing, although this is not
always possible if no other access routes are available
Twiddlers Syndrome occurs when a port is dislodged within the
subcutaneous pocket because of trauma to the site or manipulation
(twiddling) of the port by the patient. When this occurs, the port is noted
to move easily under the skin. Resistance may also be noted when attempting
to infuse and swelling may occur at the site. If this occurs, stop using the
port and notify the Physician to re-stabilize or re-insert the port.
______________________________________________________________________
____________________________________________________________________
8. Post insertion assessment of IVAD is completed q ___ minutes x _____.
9. Monitor site patency and rate of IV infusion q ___.
10. Heparin is only used when _________________ an IVAD.
Answers:
1. subcutaneous tissue, upper chest.
2. Non-coring or SafeStep needle.
3. T
4. Portal body, Septum, Reservoir, Catheter
5. Internal device, no dressing or site care, can be permanent, unrestricted activity,
decreased risk of infection, no external components to break, no body image impact, may be
used as long as the device is required, functional, and is not a source of sepsis.
6. Needle access is required, surgical procedure required to insert/remove
7. Patient education
8. q 30 minutes, x 2
9. q 1 hour
10. De-accessing
41
42
43
Complications Associated
With
Central Venous Catheters
44
Catheter Dislodgment
Pulmonary embolus
Infection
Device Malfunction
Venous Thrombosis
Occlusion
Perforation
Extravasation
Phlebitis
Broken or damaged
catheter tip
Air Embolism, Infection, & Occlusion are the 3 most common complications, and will be
discussed in more detail below.
Complications generally associated with the insertion procedure are:
Cardiac
Pneumothorax
Bleeding
Hematoma
Dysrhythmias
Hemothorax.
An AIR EMBOLISM is potentially the most deadly complication associated with CVCs. It
can occur as the catheter is inserted, but the risk of air embolism is present as long as the
catheter is in situ.
It appears it is the speed with which air enters the system, rather than the amount that
increases the risk
INFECTION
Infection is the most common complication of CVCs.
When infusing parenteral nutrition through CVCs , infection rates increase dramatically.
The literature suggests that common contaminating organisms are those which colonize
the skin.
The likely port of entry is still debated but it appears to be from openings in the IV
system or at the catheter hub.
Organisms may also track down the tunnel, from the exit site and into the accessed vein.
CVCs occluded for >24 hours increase the patients risk of infection exponentially! Treat
blocked CVCs AS SOON AS POSSIBLE!
Good hand hygiene before catheter insertion or maintenance combined with proper aseptic
technique during catheter manipulation provides protection against infection.
46
OCCLUSIONS
Central Venous Catheter (CVC) occlusion is the most common non-infectious complication
related to CVCs. A normally functioning CVC should flush easily and there should be
free-flowing blood return.
Partial and complete thrombotic occlusions are responsible for approximately 58% of all
occlusions and develop as fibrin builds on and around the catheter and vessel. Blood
components and cells adhere to fibrin, restricting blood flow and providing a place for
bacterial growth. The formation of fibrin begins within 24 hours of catheter insertion.
Thrombotic occlusions include fibrin sheath, fibrin tail, intra-luminal occlusion, and mural
thrombis. Thrombotic occlusions of a CVC can result in interruptions or delays in
therapy, infection, embolism, or loss of vascular access. Proper care and maintenance,
continued assessment, and early recognition of the pending signs of occlusions can
improve patient outcomes and minimize organizational costs.
FIBRIN SHEATH
FIBRIN TAIL
47
Non-thrombotic causes account for 42% of occlusions and include drug precipitates,
lipid deposits, and mechanical obstructions. Drug precipitation occlusions can be avoided
by thoroughly flushing the CVC between incompatible medications. Lipid occlusions can
be recognized by observing increasingly sluggish blood return in the lumen used to
administer Parenteral Nutrition (always the Medial lumen on a triple-lumen CVC),
resistance to flushing, lack of free-flowing blood return, or complete inability to infuse
or flush.
If a catheter is partially or completely blocked as a result of drug precipitate or lipid
PREVENTION OF OCCLUSIONS
Prevent occlusions by turbulent flushing before & after use, between incompatible
medications, after blood draws, and regular flushes of lumens not in use
If there is resistance to flushing, lack of free-flowing blood return, or complete
inability to infuse or flush call an RN who has been competency assessed to unblock the
CVC (this may vary from site to site so check your local guideline)
48
INFECTION
- Local or site
infection
- Systemic or intraluminal infection
- Incidence 3-10% (varies with device
used)
OCCLUSION
Most common
complication may occur
as a result of fibrin
sheath formation/
thrombus at the tip of
catheter, blood clots,
lipids or precipitates
within the catheter
lumen or catheter
malposition
AIR EMBOLISM
Due to:
cut in line
catheter
dislodgment
catheter
separation
(see Figure 1)
air in line
Fever/chills
Increased WBC
Malaise
Purulent drainage,
erythema, swelling,
tenderness at site
Inability to infuse or
withdraw from catheter
Early sign - ability to infuse
fluids, but the inability to
aspirate blood
Symptomatic
Anxiety, restlessness,
apprehension,
chest/shoulder
pain
Change in level of
consciousness
Dyspnea
Shock/vascular collapse
Cardiac arrest
Asymptomatic/Potential for
Air Embolism
DEVICE
MALFUNCTION
NURSING ACTIONS
Internal Causes:
Pinch off syndrome*
Rupture of the catheter
from
excess flushing pressure
External Causes:
Improper clamping
Use of scissors or other
sharp objects
Use of needles through the
Position flat
Aspirate air, change IV set-up, flush and reconnect
system prn
Internal:
Always check device for any signs of
damage (e.g. cracks or leaks)
External:
Prepare for insertion of a new catheter by
physician
Temporary or permanent repair is possible in some
catheters including PICCs and tunneled CVCs. Call
General Daycare or Home IV RN.
49
COMPLICATION
NURSING ACTIONS
injection cap
Constant moving and
bending of elbow/shoulder
in PICCs
Twiddlers syndrome (see
pg 43)
EXTRAVASATION
More common in
IVADs when the
needle becomes
displaced
CATHETER
DISLODGMENT
OR MIGRATION
CENTRAL VEIN
PERFORATION
Rare complication
associated
with left sided
insertion
PHLEBITIS
Due to chemical or
mechanical irritant, e.g.
- irritating IV fluids
catheter movement
Most often seen in
PICCs
Pain
Erythema
Occlusion
Swelling
Hot skin to touch
If partial dislodgment:
- stabilize catheter
- decrease rate to TKVO
- change solution to normal saline
- position patient flat
- notify physician
If completely dislodged:
- apply pressure to site
Asymptomatic:
- position patient flat
- apply pressure x 5 minutes, then
pressure dressing
- monitor for S&S of air embolism
- notify MD
Symptomatic:
- position patient on left side Trendelenberg
- initiate resuscitative measures as necessary
- obtain help & call Physician STAT
- continue to apply pressure for 5 minutes
Assess patient post insertion
Apply O2
Notify Physician STAT if not at bedside
Initiate cardio pulmonary
resuscitation as necessary
50
COMPLICATION
PNEUMOTHORAX
Accumulation of air in
the pleural cavity
often associated with
insertion technique
Increased incident
during
placement of a
subclavian
catheter
VENOUS
THROMBOSIS
Rare 1-16% of CVCS
May occur with short or
long-term catheters
Dyspnea
Cyanosis
Chest pain
Pain behind clavicle
Hypotension
Tachycardia
Asymmetrical chest
movement
Decreased/absent breath
sounds
Arm or neck swelling
External jugular distension
Pain
Numbness
Weakness on affected side
NURSING ACTIONS
Observation
Removal of catheter on physicians order
Long-term anticoagulation (3-6 months)
Thrombolytic therapy
Figure 1
51
52
Answers
1. air embolism
2.
ensure the lumen is clamped prior to opening the system
- use luer-lock connections
- keep blue clamps/padded forceps with patient in case of catheter
breakage
- have patient perform valsalva maneouver when risk of air embolism is high
- trendelenberg or flat positioning during insertions and removal of
catheter
3. chest, breath
4.
the positioning of the patient on their left side in
Trendelenberg position
- clamping the CVC (between the patient and air if possible)
- cardiac and respiratory resuscitation measures
- notify the physician
5. infection, air embolism, or occlusion
6. infection
7. occlusion
8. positive displacement cap
9. infection
53
CARE
AND MAINTENANCE OF
CENTRAL
VENOUS CATHETERS
54
Electronic infusion pumps must be used for all infusions administered through a CVC in the
acute care setting
(**Exception Blood is not to be given through a pump at some sites. Check your local
Blood Administration guideline)
All connections must be luer-locked.
IV Tubing changes:
o Acute & Residential Care:
Primary Administration tubing changed q96h (TPN tubing q24h, blood q4h or
4 units)
Intermittent infusion sets are changed a minimum of q 24 hours, when
contaminated, and after each use.
o Community Care:
Change tubing q 24 hours in clinic setting
Change tubing q72 hours and prn in home setting
All IV bags with factory added medications changed q96h
All IV bags containing site added medications (including pharmacy added) changed q24h
Luer-lock extension tubing on CVCs without clamps are changed with IV tubing and add-on
devices q96h
(**Exception - The extension tubing that is added to a PICC line immediately after
insertion is considered part of the PICC and is never changed. If the PICC needs to be
CLAMPS
Clamps must be used when accessing and de-accessing an open-ended CVC to prevent air
embolism or blood backflow.
Open-ended catheters are clamped at all times when not in use
Clamps are not used on a valved CVC
A padded forceps must be available at all times in the event of a break in the catheter
lumen
Do not use a sharp edged clamp or hemostat as they can damage the catheter
Only clamp the reinforced segment of the catheter
FLUSHING
Always use 10ml syringes for flushes for CVC as excessive pressure
(caused by syringes smaller than 10 mL when flushing and syringes greater than 10 mL
when aspirating) can cause catheter damage
Flushing ensures patency of the catheter
All unused lumens must be flushed at specific intervals
Turbulent flush method (stop/start) should be used
56
Short Term
CVC
Type of Device
Open Ended
Open-Ended
Closed-end
Long Term
Tunneled
(i.e.Hickman/Broviac)
Open
Closed-end
ended
Closed end
Sterile
SODIUM
CHLORIDE
O.9% 20 mL
Once a
month
Solution for
final flush (Lock
solution)
Sterile SODIUM
CHLORIDE
O.9%
20 mL
Sterile
SODIUM
CHLORIDE
O.9% 20 mL
Sterile
SODIUM
CHLORIDE
O.9% 20
mL
Sterile
SODIUM
CHLORIDE
O.9% 20
mL
Sterile
SODIUM
CHLORIDE
O.9% 20 mL
Sterile
SODIUM
CHLORIDE
O.9% 20 mL
followed by
HEPARIN 10
units/mL (3 to
5 mL)
Frequency of
flush for
unused lumens
Q24H
Q24H
Q7 Days
Q24H
Q7 Days
Once a
month
Flush capped
CVC
Sterile SODIUM CHLORIDE O.9% 10 mL pre-flush & between meds, followed by Sterile SODIUM CHLORIDE
O.9% 20 mL post-flush, capping, or after blood draw
Patency
Assessment
All CVCs must be assessed for patency before each use - patency is assessed by the ability to aspirate for blood
return AND the ability to flush a CVC without resistance prior to the administration of parenteral medications and
solutions. If line is not patent, assess for an occlusion (refer to Guideline).
General
Considerations
- Always use aseptic technique and observe hand hygiene. Flushes must be done with a 10mL syringe. Use
turbulent flush method (stop/start).
DRESSINGS
57
BLOOD SAMPLING
Peripheral sampling is the Gold Standard and should be done whenever possible
and/or when the clinical situation does not preclude the use of peripheral sampling
Blood must be drawn in a certain order. Refer to the Fraser Health Lab Accessioning
Manual for further information.
Use the largest lumen (usually distal) of multi-lumen CVCs whenever possible. This will
prevent the development of occlusions from a thrombus or fibrin tail/sheath.
Have a dedicated lumen for blood draws if able. Never use the same lumen for TPN and
blood draws.
Stop all infusions prior to blood sampling. For drug levels, it is not recommended to
draw the level from the same lumen being used for the drug infusion.
When drawing blood from a CVC with a continuous infusion running without the use of a
connector/ positive displacement cap, stop the infusion(s), remove the administration
set, and attach the luer lock vacutainer directly to the catheter lumen.
For a capped CVC, luer lock the vacutainer directly to the connector/ positive
displacement cap and then change connector/ positive displacement cap following the
blood draw. Exception: Blood Cultures should always be drawn directly from the
catheter hub. If a cap is necessary, draw blood cultures through a new cap and change
it again to another new cap when blood draw is completed.
Use a needless or needle-safe system whenever possible. The use of the syringe
method which utilizes a needle to fill the blood tubes is not a needle-safe method.
Discard amount:
The discard amount when drawing blood is 5 mL. The only exception is when drawing
coagulation studies, the discard amount should be 10 mL.
In all cases, non-additive tubes should be used to collect the discard.
Do not discard before drawing blood cultures. Always draw blood cultures (when
required) first. If other bloodwork is needed, consider the blood culture to be your
discard amount.
Post flushing:
Draw the blood, change the positive displacement cap (when one is present), and then
flush the CVC with 20 mL NS.
58
Flat,
o
o
o
o
ASSESSMENT
Pre-Insertion:
Respiratory assessment including: breathing patterns, depth and symmetry of breath sounds
You may apply warm compress to arm above PICC insertion site QID x 20 minutes for 3
days. This is to prevent mechanical phlebitis.
NO blood pressures or venipunctures to be completed on arm where a PICC has been inserted
Subcutaneous emphysema
Bleeding
Air embolus
Pneumothorax
Ventilated patients:
-
Cardiac dysrhythmias
59
System check:
-
Catheter is secure.
Assess vital signs and neurovascular status of the extremity distal to the catheter
insertion site.
Assess the current coagulation values. (consult physician before removing if patient
has elavated coagulation values, is on anti-coagulants, or has a pacemaker).
Assess the catheter site for signs of infection (i.e., redness, warmth, tenderness,
swelling, and presence of drainage.)
Place the patient supine in a slight Trendelenburg position. The level of the catheter
site should be below the heart to prevent air embolus during removal. Place the
patient flat if Trendelenburg is contraindicated or not tolerated by the patient,
or if a femoral CVC will be removed. If the CVC is in the femoral vein, extend
the patients leg and ensure that the groin area is adequately exposed.
If removing an internal jugular or subclavian catheter, ask the patient to take a deep
breath in and hold it. This causes a valsalva response. If a valsalva response is
contraindicated, such as with glaucoma or retinopathy, the patient should be asked to
exhale during the removal. If the patient is receiving positive-pressure ventilation,
60
withdraw the catheter during the inspiratory phase of the respiratory cycle or
while delivering a breath via a bag valve mask device.
Gently withdraw the catheter, pulling parallel to the skin and using a constant, steady
motion. If resistance is met, do not continue to remove the catheter. Notify
practitioner immediately.
As the introducer exits the site, apply pressure with petroleum-based ointment and
sterile gauze (or a petroleum impregnated sterile gauze dressing). The distal end of
a multilumen catheter should be removed quickly because the exposed proximal
and medial openings could permit the entry of air.
Upon removal of the catheter, inspect the tip for integrity & length. Place the
catheter on a moisture-proof pad and dispose of properly. If an infusion-related
infection is suspected, a segment of the catheter may be sent for culture. If
damage to or fragmentation of the catheter is observed, additional assessment,
such as a chest radiograph, is warranted.
Continue applying firm, direct pressure over the insertion site with petroleum-based
ointment and sterile gauze (or a petroleum impregnated sterile gauze dressing),
sealing the site until bleeding has stopped. Because CVCs are placed in large veins,
it may take up to 10 minutes for hemostasis to occur. Pressure may be needed
for a longer period of time if the patient has been receiving anticoagulant
therapy or if coagulation studies are abnormal.
Maintain bed rest for at least 30 minutes after catheter removal. Assess the site for
signs of bleeding every 15 minutes times 2, and prn (i.e. every 30 minutes times 2, then
1 hour later as needed).
Change dressing and assess site every 24 hours after catheter removal until site is
epithelialized.
61
INFECTION CONTROL
All staff will follow the latest Infection Control Guidelines for Principles of Infection Prevention
and control, Routine Practices (including hand hygiene, application of personal protective
equipment, and sharps handling and disposal) and Additional Precautions, and blood and body fluid
spills clean-up.
Prior to all procedures, clean dressing cart or bedside table using bactericidal wipes.
Hand hygiene - cleanse hands using hospital approved alcohol hand gel as per Infection Control
protocol.
Mask and wear sterile gloves for all times that the line is opened (eg. cap change), the site is
uncovered, and with all immunocompromised patients.
All positive displacement IV caps and injection ports must be cleansed with a 70% Alcohol swab
for 30 seconds and let dry completely prior to accessing.
Positive displacement IV caps are changed q96 hours, after blood draws, or when contamination
is suspected.
Blood Cultures:
o
For the diagnosis of a Central Line Associated Bloodstream Infection (CLABSI), it is recommended that one aerobic Blood Culture set (two green
aerobic bottles) be drawn from each lumen of the suspect CVC AND one
Blood Culture set (two green aerobic bottles) be drawn from a peripheral site
HOWEVER, if the source of sepsis is unknown, samples need to be
collected from at least 2 sites; one set drawn percutaneously from a
peripheral vein and one set drawn through the CVC. One set is drawn with two
aerobic bottles, the other set with one aerobic and one anaerobic bottle.
Additionally with a suspect CLA-BSI, once the CVC is removed send the
suspect catheter tip (distal 4-5 cm) to the lab in a sterile C&S container for
semi-quantitative culture (see FH Laboratories Microbiology Manual).
UB D
O Y
OU S
W
ICH H
CRUB?
WH
HUB
DO
YOU
SCRUB?
HICH
62
Reposition patient
Re-aspirate for blood. If you have free-flowing blood return, proceed with flush
If a positive displacement cap is present, remove the cap and try to aspirate from a
syringe connection directly with the catheter hub
If air is present (remember to scrub the cap/CVC hub with an alcohol swab for 30 seconds
and allowing to dry before accessing):
Withdraw air from catheter using a syringe
Remove the syringe from the positive displacement IV cap
Expel the air from the syringe.
Insert new syringe with NS and flush.
Remove syringe
Clamp line
63
REPORTABLE CONDITIONS
Report the following conditions to the Physician:
Inappropriate fluid administration
Non-functional/dislodged catheter
Changes in patient assessment (vital signs)
Changes in CVC assessment that may indicate:
o
Bleeding
Cellulitis
Check catheter length. If length of visible portion (external to insertion site) is greater than 4
cm from the length stated on the insertion record, notify Physician.
64
2.
3.
4.
Percutaneous CVC site dressings are changed q10days and prn. T F ____________
T F ____________
T F ____________
6.
Capped short-term, percutaneous CVCs should be flushed immediately after capping,
blood work, IV medications, and q12hours.
T F ____________
7.
Blue dead-ended caps are acceptable to cap a CVC in the FHA. T F ____________
8.
9.
10.
State
a)
b)
c)
d)
11.
12.
When performing a blood draw from a CVC, ___ tubes(s) of blood must be discarded.
____________________
65
Answers:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
You have just completed a self-learning module that has outlined the
basic principles of central venous catheters!
66
REFERENCES
AACN Procedure Manual for Critical care (5th ed.). Philadelphia: W.B. Saunders Company. Pg. 647.
Alexander, J., Corrigan, A., Gorski, L., Hankins, J., & Perucca, R. (2010). Infusion Nurses Society Infusion Nursing An
Evidence-Based Approach. St. Louis, Missouri: Saunders Elsevier.
Bard Access Systems Inc. (2007) Nursing Procedure Manual. Author: Salt Lake City, UT.
Beasley, C., & Mullally, S. (2007). In Craig J. V., Smyth R. L. (Eds.), The evidence-based practice manual for nurses
(second ed.). Philadelphia:Churchill Livingstone Elsevier.
Berreth, M. (2010) Clinical concepts of infusion therapy: Assessment and treatment of central vascular access device
occlusion. Infusion Nurses Society Online. 32(2). P.6-10.
Bishop, L. et al (2007) Guidelines on the insertion and management of central venous access devices in adults.
International Journal of Laboratory Haematology. 29 (261-278).
Canadian Blood Services (2007) Clinical Guide to Transfusion. Retrieved from http://www.transfusionmedicine.ca
January 11, 2011.
Canadian Nurses Association. (2008). Code of Ethics for Registered Nurses. Ottawa:ON: Author. Available from:
http://www.cna-aiic.ca/CNA/documents/pdf/publications/Code_of_Ethics_2008_e.pdf
Center for Disease Control and Prevention (2011) Guidelines for the prevention of intravascular catheter-related
infections. Author.
Center for Disease Control (2009) Central Line-Associated Bloodstream Infection (CLABSI) Event. Author.
Cohen, M. & Smetzer, J. (2008) Errors With Injectable Medications: Unlabeled Syringes are Surprisingly Common.
Hospital Pharmacy. 43(2). Pg. 81-84.
College of Registered Nurses of British Columbia (2010) Scope of practice for Registered Nurses: Standards, limits
and conditions. Pub. No. 433. Vancouver, BC: Author.
Cummings-Winfield, C., & Mushani-Kanji, T. (2008). Restoring patency to central venous access devices. Clinical
Journal of Oncology Nursing, 12(6). 925-934.
ECR Institute (2008) Needleless connectors: Evaluation. Health Devices. 37(9).
Edwards Lifesciences (2002) Quick Guide to Central Venous Access. Author.
Farjo, L. (2003) Blood collection from peripherally inserted central venous catheters. Journal of Infusion Nursing.
26(6).
Fraser Health Authority (2008) Accessioning Protocol for Pre-Analytical Handling of Blood Collection Tubes and
Capillary Microcollection Samples.
Fraser Health Authority (2009). Alteplase (Cath-Flo). Parenteral Drug Therapy Manual (Adult).
Fraser Health Authority (2011) Central Venous Catheter Care and Maintenance (Adult): Clinical Practice Guideline.
Fraser Health Authority (2010) Scope of Practice. Author.
Fraser Health Authority (2009) Test: Blood Culture. MIC 02160, Microbiology. Laboratory Medicine and Pathology
Sample Collection and Dispatch Instructions.
Fraser Health Authority (2006) Test: Catheter tip (Intravascular/IV) Culture. MIC 0250, Microbiology. Laboratory
Medicine and Pathology Sample Collection and Dispatch Instructions.
67
Garland, J., Alex, C. Mueller, C., et al (2001) A randomized trial coparing povidine-iodine to a chlorhexidine gluconateimpregnated dressing for prevention of central venous catheter infections in neonates. Pediatrics. 107(6). Pg.14311436.
Government of British Columbia. (2009) Regulation of the Minister of Health Services: Health Professions Act [Nurses
(Registered) and Nurse Practitioners Regulation, B.C. [Reg. 284/2008 amendments.] Victoria: BC.
Hadaway, L. (2009) Fluid container hang times. Lynn Hadaway Associates, Inc. Blog.
Hadaway, L. & Richardson, D. Needless connectors: A primer on terminology. Journal of Infusion Nursing. 33(1).
Hadaway, L.C. (2005). Reopen the pipeline. Nursing 2005, 35(8). 54-61.
Hadaway, L. (2006) Technology of flushing vascular access devices. Journal of Infusion Nursing. 29(3).
Hartkopf Smith, L. (2008). Alteplase for the management of occluded central venous access devices: Safety
considerations. Clinical Journal of Oncology Nursing, 12(1). 155-157
Ho, K., & Liton, E. (2009) Chlorhexidine-impregtnated dressing to prevent vascular and epidural catheter colonization
and infection: a meta-analysis.Journal of Antimicrobial Chemotherapy.58. Pg. 281-287.
th
Infusion Nurses Society (2011) Policies and Procedures for Infusion Nursing (4 ed.). Author.
Infusion Nurses Society (2011) Infusion nursing standards of practice. Journal of Infusion Nursing. 34(1S).
Knue, M., Doellman, D., Rabin, K., & Jacobs, B. (2005) The efficacy and safety of blood sampling through peripherally
inserted central catheter devices in children. Journal of Infusion Nursing 28(1).
Lobiondo-Wood, G., & Haber, J. (2009). In Cameron C., Singh M. D. (Eds.), Nursing research in Canada (second ed.)
Toronto, Ontario: Mosby Elsevier.
McGee, D. & Gould, M. (2003) Preventing complications of central venous catheterization. New England Journal of
Medicine. 348(26).Pg. 2684-6.
McKnight, S. (2004). Nurses guide to understanding and treating thrombotic occlusion of central venous access
devices. MedSurg Nursing, 13(6). 377-382.
Martinez, J., DesJardin, J., Aronoff, M., Supran, S., Nasraway, S., & Snydman, D. (2002) Clinical utility of blood
cultures drawn from central venous or arterial catheters in critically ill surgical patients. Critical Care Medicine. (30)1.
Mathew, A., Gaslin, T., Dunning, K., & Ying (2009) Central catheter blood sampling: The impact of changing the
needless caps prior to collection. Journal of Infusion Nursing. 32(4).
Mermal, L. et al (2009) Clinical practice guidelines for the diagnosis and management of intravascular catheter-related
infection: 2009 update by the Infectious Diseases Society of America. Clinical Infectious Diseases. 49.
Olsen, K., Hanson, J., Gilpin, J., & Heffner, T. (2004) Evaluation of a no-dressing intervention for tunneled central
venous catheter access exit sites. Journal of Infusion Nursing. 27(1).
Penwarden, L. & Montgomery, P. (2002) Developing a protocol for obtaining blood cultures from central venous
catheters and peripheral sites. Clinical Journal of Oncology Nursing. 6(5).
Provonost, P. et al (2006) An intervention to decrease catheter-related bloodstream infections in the ICU. New
England Journal of Medicine. 355. Pgs. 2725-2732.
Raad, I., Hanna, H., & Darouiche (2001) Diagnosis of catheter-related bloodstream infections: Is it necessary to
culture the subcutaneous catheter segment? European Journal of Clinical Microbiology and Infectious Disease.
20(566-568).
Registered Nurses Association of Ontario (2008) Nursing best practice guideline: Assessment and device selection for
vascular access. (S). Author.
68
Registered Nurses Association of Ontario (2008) Nursing best practice guideline: Care and maintenance to reduce
vascular access complications. (S). Author.
Safer Healthcare Now! Campaign (2009). Getting started kit: Prevent central line infections. Institute for
Healthcare Improvement.
Singh Joy, S. & Kayyali, A. (2010) Changing central catheter caps improves blood analysis. American Journal of
Nursing. 110 (2).
Sydney South West Area Health Service (2007) Central Venous Access Device (CVAD) Position Confirmation. Author.
Venetec Statlock Securement Device. Instructions for Use.
Weinstein, Sharon M. (2007). Plumer's Principles & Practice of Intravenous Therapy (8th ed.). Philadelphia, MD:
Lippincott Williams & Wilkins.
Wheeler, D., Wong, H., & Shanley, T. (2007) Pediatric Critical Care Medicine: Basic Science and Clinical Evidence.
Springer-Verlag: London. Pg. 257.
Yong-Gang, L., Hong-Lin, D., & Wang, L. (2009) Chlorhexidine-impregtnated sponges and prevention of catheterrelated infections. Journal of the American Medical Association. 302(4). Pg. 379.
69
APPENDICES
APPENDIX A: Responsibility for CVC Management
APPENDIX B: Central Venous Catheter Insertion and Removal Form
APPENDIX C: Regional CVC Maintenance Worksheet
APPENDIX D: CVC Skills Inventory
70
Who is Responsible
Competency Assessed RN
Competency Assessed RN
Competency Assessed RN
Competency Assessed RN
Insertion of PICC
Physician or
Advanced Competency Assessed RN
Advanced Competency Assessed RN
Advanced Competency Assessed RN
Competency Assessed RN on specified care
units
Competency
Physician
Competency
Competency
Competency
Assessed RN
Assessed RN
Assessed RN
Assessed RN
Competency Assessed RNs shall perform the following Central Venous Catheter (CVC)
Competencies:
71
72
73
CNE/Mentor
Signature
CNE/Mentor
Signature
CNE/Mentor
Signature
5) Specialized Skill: Blood sampling from a CVC (vacutainer and/or syringe method)
Date of Theory & Lab CNE Signature
Clinical Performance
CNE/Mentor
Evaluation date
Signature
6) Specialized Skill: Accessing an Implanted Port
Date of Theory & Lab CNE Signature
Clinical Performance
Evaluation date
CNE/Mentor
Signature
CNE/Mentor
Signature
CNE/Mentor
Signature
74
75
76
2011
77