Central and PICC Lines

Care and Best PracticesMary Larson, SN

St. Cloud State University

Mary Larson

Hometown: Atwater, MN St. Cloud State University Nursing Program: December 21st

Capstone Semester Preceptor: Jamie Daniel 180 Direct Patient Care Hours, 90 Leadership Hours (40 at Meeker

Memorial) Leadership Project- Teaching

Pre-Quiz

Central Venous Access Catheters inserted into large veins in central circulation Tip of catheter threaded to reside in lower third of the vena cava Chest X-ray to confirm correct placement

Central Venous Access

Indications: Patients requiring multiple sites for IV access Patients lacking useable peripheral IV sites Patients requiring central venous pressure monitoring Patients requiring total parenteral nutrition Patients receiving incompatible medications Patients requiring multiple infusions of fluids, medications, or chemotherapy Patients requiring long term antibiotic therapy Patients subject to frequent blood sampling or receiving blood transfusions Patients requiring a temporary access site for hemodialysis Patients receiving infusions that are hypertonic, hyperosmolar or infusions

that have divergent pH value

Non-Tunneled Percutaneous Central Venous Catheter AKA Central Line Inserted by physician Subclavian vein of upper chest or internal jugular veins in the neck Occasionally femoral – higher rates of infection Measure 7-10 inches (18-25 cm) 1 to 5 Lumens Used most common: Trauma, critical care, surgery No recommended dwell time: used for short term, not the catheter of

choice for home care or ambulatory clinic settings

Peripherally Inserted Central Venous Catheters (PICC)

Long catheter, inserted in vein of antecubital fossa or middle of upper arm

Basilic vein preferred, cephalic used if necessary Inserted by physicians or specially trained nurses Length 18-29 inches (45-72 cm), 1-3 Lumens Optimal dwell time unknown: reported to dwell successfully for

months or even years Lower rate of Central Line Assoc. Bloodstream Infections (CLABSI)

than Central Lines Patients requiring lengthy antibiotics, chemotherapy, parenteral

nutrition, or vasopressor agents – benefit from PICC line.

Lumens Central Line: 1-5 PICC Line: 1-3 Port Designation: (with 3 Lumens)

Proximal Blood Sampling Medications Blood Administration

Medial TPN Medications (Only if TPN use in not anticipated)

Distal CVP monitoring Blood Admin High Volume or Viscous Fluids Colloids Medications

Catheter Dressings Centers for Disease Control and Prevention (CDC)

Recommendations: Use either sterile gauze or sterile transparent semipermeable

dressing If pt is diaphoretic or site is bleeding or oozing, use gauze until

resolved Replace dressing if damp, loosened, or visibly soiled Do not use antibiotic ointments or creams Dressing changes:

Short-term CVC sites q 2 days for gauze and at least q 7 days for transparent

PICC-24 hours post insertion, then transparent dressings q 5-7 days unless soiled or loose, gauze q 2 days unless wet, soiled, or non-occlusive

>5% Chlorhexidine to cleanse skin during dressing changes

Dressing Changes

Dressing Removal: Stabilize catheter and Luerlock hub to prevent dislodgement Separate dressing away from Luerlock hub and toward insertion site

Chlorhexidine should be used to swab in a back and forth pattern for 30 seconds to ensure the skin is clean and disinfected

If patient is diaphoretic with a great deal of fluid present on skin, area should be scrubbed for 2 minutes to ensure bactericidal activity

During dressing change- assess external catheter length to determine if migration had displaced catheter tip

Sterile occlusive dressing should cover entire insertion site, suture wing and at least 2.5 cm of the extension tubing is recommended

Dressing Change Procedure Gather supplies Hand hygiene Don clean gloves and mask (patient) Remove old dressing (toward insertion site) and discard Remove gloves, perform hand hygiene, and don sterile gloves Inspect catheter, site, surrounding skin, and pt’s arm/chest/neck Cleanse site (chlorhexidine) back and forth motion Allow to air dry Secure catheter in place Apply sterile dressing to site Document date, time, and initials on new dressing Document the procedure, any complications, and external catheter

length to patient’s chart

Caps: Needleless Access Devices CDC recommends changing caps at least as frequently as

administration sets No benefit to changing these more frequently than every 72 hours TPN/Lipids (enhance microbial growth) Accessing: “Scrub the Hub” for 15 seconds Types:

Negative Displacement Device Neutral Displacement Device Positive Displacement Device

At Meeker Memorial: Baxter Clearlink System (Negative Displacement)

Flushing Lines A single use syringe should never be used more than once 10 mL syringes should not be divided into several doses and used for

multiple lumens Never use a syringe smaller than 10 mL

The pressure created by smaller syringes could damage the catheter Volume: Minimum of twice the volume of the catheter should be used

to flush In general for adults 10 ml is sufficient

0.9% NaCl solution should be used Frequency: If being used a minimum of q 8 hours, flush with 10 mL NS

before and after every use and for lines in maintenance mode flush with 10 mL NS every 24 hours.

Flush using a pulsative or “stop-start” technique Creates turbulence within the catheter to adequately flush medications

from the line

Preventing: Blood Reflux Major problem Catheters are deep in the body, reflux cannot be seen when it occurs Caused by inadequate flushing, also b/t flushes caused by increased

intravascular pressure (ex: coughing, vomiting) leading to biofilm formation and buildup, occlusion, and even infection

Prevention Strategy: Know which type of needleless connector is being used. Negative Displacement (Meeker Memorial – Baxter Clearlink System)

Catheter must be clamped BEFORE syringe is removed Neutral Displacement

Fluid should remain neutral, therefore clamping can be done before or after syringe removal

Positive Displacement Important to clamp the catheter AFTER the syringe is removed in order to get

displacement

https://www.youtube.com/watch?v=X5wIhmR0SIE

Assessment Visually examine insertion site daily for erythema, drainage,

tenderness, suture integrity, and catheter position Routine IV site assessments Routinely assess dressings (change if necessary) Daily assessment of need for Central Line and promptly discontinue

lines which are no longer indicated Nursing staff should be encouraged to notify physicians of Central

Lines which are unnecessary

Documentation The following should be included in the patient’s chart:

Product Name Date of insertion, inserter Anatomical location Catheter depth according to catheter reference markings X-ray confirmation of catheter tip location Port designation for infusions/measurements, e.g. TPN, CVP, Medications

Ensures uniform use of lumens Amount, type, and frequency of flush solution Dressing and tubing changes

Document exposed catheter length with dressing changes Site assessments

Every shift Complications Catheter removal and application of air-impermeable dressing

References Angiodynamics (2014). Bioflo picc with endexo technology: Directions for use. Marlborough,

MA: Navilyst Medical, Inc. Arrow (1996). Central venous catheter: Nursing care guidelines. Reading, PA: Arrow

International, Inc. Centers for Disease Control and Prevention (2011). Basic infection control and prevention plan

for outpatient oncology settings. Retrieved from http://www.cdc.gov/HAI/settings/outpatient/basic-infection-control-prevention-plan-2011/central-venous-catheters.html

Centers for Disease Control and Prevention (2011). Guidelines for the prevention of intravascular catheter-related infections. Retrieved from http://www.cdc.gov/hicpac/bsi/bsi-guidelines-2011.html

Ignatavicius, D.D., & Workman, M.L. (2013). Medical-surgical nursing: Patient-centered collaborative care (7th ed.). St. Louis, MO: Elsevier Saunders.

Kallen, A. (2009). Central line-associated bloodstream infections (clabsi) in non-intensive care unit (non-icu) settings toolkit. Atlanta, GA: Centers for Disease Control and Prevention.

Stacey, K.M. (2014). Peripherally inserted central catheter (picc): Maintenance and dressing change quicksheet. Mosby’s Skills. St. Louis, MO: Elsevier, Inc.

Schallom, L., & Shomo, J.E. (2011). Keeping the lines open with evidence-based practice and technologies: A continuing educational activity for pharmacists and nurses. Irving, TX: VHA, Inc.

The Nebraska Medical Center (2012). Standardizing central venous catheter care: Hospital to home (2nd ed.). Omaha, NE: The Nebraska Medical Center.

Questions?

Post-Quiz