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