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Central Venous Catheter Care- A Nursing skill
- 1. CENTRAL VENOUS CATHETERCARE A NURSING SKILL Ms. Tsering Lamo ICNO, AIIMS, New Delhi
- 2. • Introduction • Definition- CVC • Common sites of insertion • Types of CVC • Indications • Technique of insertion • Contraindications • Complications • CVC care • CLABSI & CLABSI Bundle • Key Points to Remember • Patient Education • Time to talk
- 3. Introduction Central venous accessis a standard procedure performed on the hospitalized patient especially in the intensive unit.
- 4. Central Venous Catheter •Central Venous line, Central venous access catheter, Central line. • Vascular access devices inserted into large vein in the CVS. • Made of polyurethane, silicon rubber or CVC. • Commonly 15–30 cm in length. • Radiopaque • Used very frequently in ICUs.
- 5. Which VEIN Tochoose ?? • Depends on :- – Medical history & vascular history related any prior CVAD placements. – CVC type – Activity level – Preference – Duration of treatment
- 6. Common Sites ofInsertion 1. Centrally Inserted • Rt Jugular Vein • Lt Jugular Vein • Rt Subclavian Vein CDC • Lt Subclavian Vein • Femoral Vein (as a last resort)
- 7. Common Sites ofInsertion 2. Peripherally Inserted • Basilic Vein (1st choice) – Larger (diameter- 3 to 6mm) – Not in proximity of arteries or nerves • Brachial vein (2nd choice) – Close to brachial artery & medial nerve • Cephalic Vein – Only in selected pts like obese – Too superficial – Too many valves
- 8. Position of CatheterTip • Positioned inside the Superior Vena Cava • Catheter tip btw 55 & 29 mm below the level of the carina. Cavo-Atrial Junction
- 9. Types of Catheters ShortTerm Use • Single or multiple lumen • Pulmonary artery catheter (Swan Ganz) Long Term Use • Tunneled • Non –Tunneled • Implanted Port -A- Cath • PICC
- 10. 1. Proximal Lumen-18G -Blood sampling -Medications -Blood administration 2. Medial Lumen -18G -Exclusively for TPN 3.Distal Lumen -16G -CVP Monitoring -Medications -Blood administration
- 11. Tunneled Catheter • Placedunder the skin. • Used for a longer duration of time. • The exit site is typically located in the chest. • Prevent infection and provides stability. • E.g., Hickman catheter
- 12. Non – TunneledCatheter • Fixed in place at the site of insertion. • Catheter & attachments protrudes directly. • Mainly used for HD • E.g., Quinton catheters
- 13. PICC Line • Muchlonger than CVC (50–70 cm). • Smaller in diameter than central lines. • Considerably slower flow rate. • Advantage : - – Can remain in place for several wks-month – Low risk of infection & complications, – Ease of insertion, – Low cost
- 14. Implanted Port • Leftentirely under the skin. • Surgically implanted • Infusion ports are placed below the clavicle (infraclavicular fossa). • Medicines are injected through the skin into the catheter.
- 15. Implanted Port • Somecontain a small reservoir (can be refilled) • Reservoir slowly releases the med into the bloodstream. • Typically used on pts requiring periodic venous access over an extended course of therapy. • Easier to maintain & lower risk of infection
- 16. Indications 1. Administer Meds(irritant drugs) -Vasopressors, Chemo, Hypertonic sol. 2.Hemodynamic Monitoring -CVP , Cardiac Parameters etc 3. Specialized Rx -Plasmapheresis, HD
- 17. Indications 4. Parenteral feeding- TPN 5.Arrythmias (tip deep inside Rt atrium) 6. High Volume/ Flow Resuscitation - Infusion of Fluid/ Blood Products 7. Poor Peripheral Venous Access
- 18. Technique of Insertion Medicalprocedure to obtain safe access to blood vessels & other hollow organs 1. 2. 3. 4. 5.
- 19. Contraindications • Uncooperative pt •Infection at the site of access • Bleeding disorders • Pneumothorax or hemothorax • Distorted anatomic landmark from any reason
- 20. Complications 1. Pneumothorax • Inless than 1% of pts • Require hospital stay to heal (2-4days) 2. Artery Puncture • Accidental puncture of an artery (carotid) • Hematoma- blood collects outside the artery • Pts are observed for swelling • Very rare (when USG guided)
- 21. Complications 3. CLABSI • Seriousinfections • Fatal in up to 25% of cases. 4. Occlusion • Kinks in the catheter, • Backwash of blood into the catheter leading to thrombosis, • Infusion of insoluble materials that form precipitates.
- 22. Complications 5.Venous Air Embolism •Rare but lethal. • Fatal when at least 200–300 milliliters of air is introduced. • Lead to heart failure, Pul edema. 6. Misplacement • Mistakenly placed in an artery during insertion. • When anatomy of the person is different or difficult due to injury or past surgery.
- 23. CVC Care • Meticulouscare given to a patient with regard to the CVC. • To prevent- – CLABSI – Central line thrombosis, and – Mechanical complications. • Involves aseptic techniques. • Typically performed by skilled Nsg or medical staff.
- 24. CVC CARE 1. STERILEDRESSING CHANGE • Gauze dressings - every 2 days unless they are soiled, dampened or loosened. • Transparent dressings -every 7 days unless they are soiled, dampened, or loosened.(CDC) 2. CAP CHANGE • No more often than 72 hours (or acc. to manufacturer recommendations) • However, caps should be replaced when the administration set is changed. (CDC) 3. FLUSHING • Continuous • Pulsative
- 25. Articles Required 1. Asterile tray containing : - – Bowl with spirit swabs – Artery forceps – Thumb forceps – Sterile gauze – Sterile towel
- 26. Contd.. 2. A cleantray containing; - – Clean glove - 1 pair – Sterile glove -1 pair – Povidone iodine/2% Chlorhexidine sol./70% isopropyl alcohol – Kidney tray / Paper bag – Transparent dressing/Tegaderm – Normal saline/Heplock – 10ml syringe , Triway – Mask – Label – Sterillium
- 27. Procedure 1. Collect allarticles at the bedside. 2. Explain the procedure to the patient. 3. Wash hands and put on the mask. 4. Don the clean gloves. 5. Remove the previous dressing using the spirit swabs. 6. Assess the site for signs of infection, oozing, swelling etc . (if any, inform). 7. Remove the clean gloves & perform hand hygiene. 8. Open the sterile dressing set.
- 28. Procedure 9. Pour Chlorhexidine/Povidone Iodine/70% alcohol into the sterile bowl. 10. Don the sterile gloves. 11. Clean the insertion site of the CVC with the Chlorhexidine/ Povidone Iodine/70% alcohol gauze in a circular fashion. 12. Clean the catheter lines with the Chlorhexidine /Povidone Iodine/70% alcohol swabs. 13. Clean the site in concentric circles. 14. Let it dry on the skin.
- 29. Procedure 15.Apply the tegadermover the CVC insertion sites, securing the line and without any air trapped inside. 16.Scrub the injection hub with 70% alcohol (15 -30sec) & let it dry(30sec). 17.Check the back flow and flush the line with heplock/Saline. 18. Clean the caps of each line with 70% alcohol. 19. Wrap a sterile pad around the ports.
- 30. Procedure 20. Label withdate and time. 21. Replace all the articles. 22. Perform hand hygiene. 23. Record in the nurses record : - -Any redness, swelling or fever -Break or leak in catheter -Patency of all ports -Loosening of fixation -Length of indwelling catheter -Date & time of dressing
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- 33. • Syringe tobe use : Adult - 10 ml Paeds – 1-5 ml • Larger syringes: less pressure when flushing and more pressure when withdrawing or aspirating • Smaller syringes: produce more pressure when flushing less pressure when withdrawing
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- 35. Flushing Technique 1. Continuous •Continuous pushing of sol. 2. Pulsative • Allows to “scrub or clean” the inside of the device wall. • Promote removal of blood/fibrin • Help prevent buildup of medication precipitate on the internal lumen of the device
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- 39. Laboratory Confirmed Blood StreamInfection (LCBI)
- 41. CLABSI BUNDLE -HaMCOD Hand hygiene Maximal barrier precautions upon insertions/manipulation Chlorhexidine /Povidine Iodine/Alcohol skin antisepsis Optimal catheter site selection with avoidance of the femoral vein for CV access Daily review of line necessity with prompt removal of unnecessary lines
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- 44. 1. Maintain asepsisduring –medication/blood sampling & during infusion & flushing 2. Do not keep the cap over unsterile area. 3. Tip of med. Syringe should not touch unsterile area. 4. Flush after administration (SAS) of med. & after sampling (SBS) or (SASH) 5. Injection ports should be closed & covered with a sterile gauze. 6. If port of a tri-way is smeared with blood, replace the same with a sterile one.
- 45. 7. Change Gauzedressings - every 2 days unless they are soiled, dampened or loosened.CDC 8. Transparent dressings -every 7 days unless they are soiled, dampened, or loosened. CDC 9. Replace tubing that is used to administer blood, blood products, or lipids within 24 hours of initiating infusion. CDC 10. Change caps no more often than 72 hours (or according to manufacturer recommendations); however, caps should be replaced when the administration set is changed. CDC 11. Keep the IV set & the catheter as a closed system. Repeated connections & disconnections should be avoided.
- 46. 12. Fluids &drugs should not be given through the TPN line. 13. Use pressure bags during rapid transfusion. Avoid pushing through the 3 –way. 14. Once catheter is removed apply firm pressure. Take precautions not to touch the tip of catheter. Tip of catheter should be sent for C/S . Puncture site should be covered with sterile dressing & tape. Dressing should be removed after 24hrs. 14. Details of removal are documented in the records (including date, location, and signature and name of operator undertaking removal.)
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