Nursing ATI Central Venous Access

Basilic vein

Arises from ulnar side of hand, passes up forearm and joins with brachial veins to form axillary vein.

Brachial veins

Follow course of brachial artery and join with basilic vein to form axillary vein.

Catheter pinch-off

Rare complication of tunneled CVCs that occurs when the catheter is compressed between the first rib and the clavicle, causing an intermittent mechanical occlusion.

Central vascular access device

Umbrella term that includes a variety of catheters, cannulas, and infusion ports that allow intermittent or continuous central access to a blood vessel. Usually inserted into subclavian or jugular vein with distal tip resting in SVC just above right atriu

Cephalic vein

Superficial vein that arises from the radial side of the hand and winds anteriorly to pass along the anterior border of the brachioradialis muscle, ascends along the lateral border of the biceps muscle and the pectoral border of the deltoid muscle, and fi

Extravasation

Seepage or introduction of fluid, such as IV fluid, into the tissues surrounding a blood vessel; sometimes used interchangeably with infiltration, but more accurately describes catheter dislodgement with medication infusing into the tissues and causing ac

Huber needle

Noncoring device used to access an implanted port.

Implanted port

Catheter whose end is attached to a small chamber placed in a subcutaneous pocket instead of exiting from the skin, either on the anterior chest wall or on the forearm.

Infusion

Slow, intentional introduction of fluid into a vein.

Negative pressure

Pressure or force less than that of the atmosphere.

Nonthrombotic occlusion

Obstruction of a blood vessel by a means other than a blood clot.

Peripherally inserted central catheter

Catheter used for long-term IV access and inserted in the basilic or cephalic vein just above or below the antecubital space with the tip of the catheter resting in the SVC.

Pinch-off syndrome

Rare complication of a tunneled CVC that occurs when the catheter is compressed between the first rib and the clavicle, causing intermittent mechanical occlusion.

Positive pressure injection cap

Cap attached to the end of a catheter that exerts positive pressure into the line after flushing and removing the syringe, thus preventing backflow of blood into the catheter and reducing the risk of occlusion.

PSI

Pounds per square inch. Pressure a gas or liquid exerts on the walls of its container, measured in units of one pound of force or pressure applied to one square inch.

Reservoir

Portion of CVC that provides a chamber implanted in a subcutaneous pocket with a catheter attached to the chamber and inserted into a central vein.

SASH

Saline, administer, saline, heparin. Technique for administering a medication IV, involving first flushing with NS, injecting the medication, flushing with NS, then flushing with heparin.

Sepsis

Presence in blood or other tissues of pathogens or their toxins.

Subclavian vein

Vein that continues the axillary vein as the main venous stem of the upper limb, follows the subclavian arter, and joints with the internal jugular vein to form the brachiocephalic vein.

Thrombotic occlusion

Deposits of fibrin and blood components, or clots, within and around the central line that interfere with flow.

Turbulent flushing

Intermittent push-stop-push technique of quickly injecting a small amount of flush solution, pausing, then injecting again and repeating until all the flush solution has been injected.

Valsalva maneuver in CVC insertion

Increases intrathoracic pressure and thus interferes with return of blood to the heart. Creates positive phase in central venous pressure, thus reducing the risk of air being drawn into the central circulation and creating an air embolus.

Vesicant

Chemical that produces blisters.

CVAD

Central venous access device = central line. Can remain in place for more than a year.

Indications for central line

Parenteral nutrition.
Chemotherapy or other vesicant or irritating solution.
Blood products.
Antibiotics.
IV meds or solutions when peripheral access is limited.
Central venous pressure monitoring.

Advantage of multilumen catheter

Solutions do not mix as they travel through catheter. Central line may have up to 4 lumens with separate ports. Allows multiple uses simultaneously.

Common use of triple lumen ports

Distal port (16-G), largest lumen, used for central venous pressure monitoring or high volume or viscous fluids, colloids, medications.
Medial port (18-G), for TPN, medications.
Proximal (18-G), for blood sampling, medication, blood components.

4 types of central lines

Nontunneled.
Tunneled.
Implanted port.
Peripherally inserted central catheter.

Syringe size for flushing central line

10 mL or larger to avoid rupturing line with excessive pressure.

How to flush central line with NS

Use preservative free sterile NS. Use push-stop-push to create turbulence that helps clear blood and meds from line. Do not flush forcefully if you meet resistance. Troubleshoot.

How to flush a valve-tip catheter like Groshong

Requires only NS, not heparin because valve keeps blood from entering. Otherwise, use heparin flushes per policy.

Importance of clamping central line

Always clamp when not in use, including the time between changing syringes. Valve-tip does not require clamping. Clamping prevents air embolus.

Positive pressure flushing technique

Withdraw syringe from injection cap as you flush the last 0.5 mL into the catheter or flush all fluid into catheter, maintain pressure on syringe plunger, clamp tubing, then disconnect syringe. Use this technique except with positive fluid displacement ne

Drawing blood from central line

Use distal port if possible. To make sure results will not be altered, turn off distal infusions and clamp tubing for 1-5 minutes before obtaining blood sample. Resume infusion after collecting sample. Use syringe or Vacutainer to collect sample. May need

Complications of central lines

Infection.
Sepsis.
Pneumothorax.
Air embolus.
Catheter occlusion.
Thrombosis.
Drug precipitates.
Pinch-off syndrome.
Catheter malposition.
Catheter rupture.

Manifestations of pneumothorax

Dyspnea, hypoxia, tachycardia, restlessness, cyanosis, chest pain, decreased breath sounds or affected side.

Interventions for pneumothorax

Monitor VS. Administer O2. Notify provider. Patient might need chest tube and to have central line removed.

Manifestations of air embolism

Dyspnea, chest pain, tachycardia, hypotension, anxiety, nausea, dizziness, confusion.

Interventions for air embolism

Frequently check that catheter is intact and patent. Only valve-tip like Groshong can be open to air without risk of air embolus. Keep others clamped. If air embolus suspected, clamp line, give O2, and place patient on left side in Trendelenburg. Helps tr

Troubleshooting line with sluggish flow or no blood return

May indicate occlusion or malposition of tip. Can be thrombotic or nonthrombotic occlusion. First make sure line is not clamped or kinked. Tip might be resting against vein. Have patient turn head and cough. Raise arms over head. Trendelenburg position. T

How to deal with pinch-off syndrome

Occurs in lines inserted into subclavian. Will see difficulty withdrawing blood and difficulty infusing fluids. If you cannot flush or aspirate blood, have patient change position of arm by raising it or pulling shoulder backward. If this relieves occlusi

Catheter migration

Can occur for many reasons, coughing, sneezing, external manipulation. Tip can move without external catheter changing length. Tip can go where infused fluids flow against direction of blood flow. Prevention: Remove dressing carefully to prevent dislodgem

Port-A-Cath

Brand name for implanted vascular access device. Single or double injection port placed under skin with self-sealing septum covering a metal or plastic reservoir called the body. Catheter runs from reservoir to central vein, typically SVC. Used for meds l

To access implanted vascular access device

Use noncoring, nonbarbed (Huber) needle (designed to not damage septum). Usually can use same needle for 7 days. Open-ended ports need heparin. Valved ports do not. When not accessed, usually needs only monthly flushing.

Indications for nontunneled catheter

IV therapy, blood sampling, and central venous pressure monitoring.

Dwell time for nontunneled central line

3-4 weeks typically.

Disadvantages of nontunneled CVC

Risk of infection. Risk of pneumothorax.

Dwell time for PICC

Usually 1-12 weeks, but can be years.

Indications for PICC

Giving fluids, blood, meds, blood sampling, but this can be difficult because of small lumen.

PICC care

Measure arm circumference at level of axilla at baseline and later to assess for swelling. Document length of external portion to detect dislodgement. Dressing change with clear dressing 24 hours after insertion and weekly. Typical flush is every 12 hours

Insertion site care

Surgical asepsis for dressing changes. Change when damp, loose, or soiled. Change gauze dressing every 48 hours and transparent dressing every 3-7 days. Antiseptic use varies. Isopropyl alcohol not recommended for neonates. Betadine and Chloraprep must be

Indications for tunneled catheters

May be used for months to years. For fluids, chemo, antibiotics, blood, TPN, central venous pressure monitoring, blood sampling.

Trade names of tunneled catheters

Hickman, Broviac, Leonard, Groshong. Broviac is small single lumen. Not so good for blood draws. Groshong is valve-tip. No need for heparin or clamping.