NursingNursing ManagementManagement ofof VenousVenous AccessAccess Devices:Devices: AnAn OverviewOverview ofof CentralCentral VenousVenous AccessAccess DevicesDevices Mimi Bartholomay, RN, MSN, AOCN Denise Dreher, RN, CRNI, VA-BC Theresa Evans, RN, MSN Susan Finn, RN, MSN, AOCNS Debra Guthrie, RN, CRNI Hannah Lyons, RN, MSN, AOCN Janet Mulligan, RN, MS, VA-BC Carol Tyksienski, M.S.,R.N.,N.P CentralCentral VenousVenous AccessAccess DevicesDevices ((CVADsCVADs)) PeripherallyPeripherally InsertedInserted CentralCentral CathetersCatheters ((PICCsPICCs)) NonNon--tunneledtunneled catheters:catheters: SubclavianSubclavian // JugularJugular // FemoralFemoral LinesLines TunneledTunneled catheters:catheters: HickmansHickmans // BroviacsBroviacs // GroshongsGroshongs // SmallSmall BoreBore ImplantedImplanted ports:ports: PortPort--aa--cathscaths // PassportsPassports CentralCentral VADsVADs ““...first...first lineline ofof defense,defense, notnot aa devicedevice ofof lastlast resortresort”” Candidates:Candidates: Long-term therapies ( > one week) TPN Chemotherapy / vesicants Drugs with pH <5 or >9 Long term antibiotic therapy Hypertonic solutions (osmolality >600mOsm/L) ex.- 3% saline Limited venous access VerificationVerification ofof CentralCentral LinesLines ConfirmationConfirmation ofof typetype ofof centralcentral lineline andand lineline placementplacement MUSTMUST bebe verifiedverified beforebefore useuse UntilUntil verificationverification isis complete,complete, thethe cathetercatheter mustmust bebe markedmarked withwith aa redred ““unconfirmedunconfirmed cathetercatheter”” stickersticker PheresisPheresis andand dialysisdialysis catheterscatheters willwill havehave aa specificspecific labellabel attachedattached toto thethe dressingdressing ReferRefer toto NursingNursing PoliciesPolicies andand ProceduresProcedures TroveTrove 0505--0303--0101 andand 0505--0303--0404 SourcesSources toto UseUse forfor CentralCentral LineLine IdentificationIdentification ChestChest xx--rayray oror CTCT scanscan InterventionalInterventional RadiologyRadiology reportreport OperativeOperative notenote DischargeDischarge summarysummary ReferringReferring MDMD notenote OutsideOutside hospitalhospital transfertransfer notenote PatientPatient--providedprovided documentationdocumentation CentralCentral VAD:VAD: CatheterCatheter TipTip PlacementPlacement ChestChest xx--rayray mandatorymandatory beforebefore initialinitial use,use, andand ifif patientpatient isis readmittedreadmitted toto thethe hospitalhospital withwith anan existingexisting PICCPICC oror undocumentedundocumented VADVAD MUSTMUST bebe ““centralcentral”” –– Superior vena cava (SVC) Cavoatrial junction (superior vena cava/right atrial junction (SVC/RA junction) Right atrium (RA); exception is PICCs Femoral lines: tip in thoracic inferior vena cava (IVC) above level of the diaphragm VenousVenous anatomyanatomy ofof upperupper extremityextremity veinsveins Retrieved from Images.MD at Treadwell Library 12/11/09 CentralCentral VADsVADs:: MalpositionedMalpositioned catheterscatheters CatheterCatheter shouldshould notnot bebe usedused asas aa centralcentral VADVAD untiluntil itit isis repositionedrepositioned andand tiptip isis confirmedconfirmed toto bebe inin aa centralcentral locationlocation InterventionsInterventions forfor PICCPICCss:: Malpositioned PICCs are not automatically removed. Pull-back: if tip in right atrium, right ventricle, some contralateral PICCs, or patient is experiencing cardiac irritability, the PICC may be pulled back by the IV nurse or interventional radiology. Other tip locations may be exchanged by IV nurse or Interventional Radiology (IR). CentralCentral VADsVADs:: MalpositionedMalpositioned catheterscatheters InterventionsInterventions forfor PICCsPICCs (cont.):(cont.): Catheter exchange is considered if: • Tip is in the jugular, contra-lateral vein, coiled or looped. Most coiled or looped PICCs are managed by IR. • Patient needs more lumens for therapy or patient needs a non-violated line for TPN initiation. IndividualIndividual patientpatient anatomyanatomy oror diseasedisease maymay notnot allowallow centrallycentrally--placedplaced lineslines andand needneed isis determineddetermined onon anan individualindividual patientpatient casecase basis.basis. VeinVein MeasurementsMeasurements LengthLength DiameterDiameter FlowFlow RateRate CephalicCephalic 38cm 6mm 40-90ml/min BasilicBasilic 24cm 8mm 90-150 ml/min AxillaryAxillary 13cm 16mm 150-350ml/min SubclavianSubclavian 6cm 19mm 350-800ml/min InnominateInnominate 2.5cm 19mm 800-1500ml/min SVCSVC 7cm 20mm 2000ml/min CentralCentral VADVAD CareCare andand Maintenance:Maintenance: FlushingFlushing Always use a 10ml or larger syringe to flush or administer medications. Smaller syringes have increased flushing pressure that cause catheter rupture. Note: some pre-filled syringes smaller than 10ml have syringe barrel equal to a 10 ml syringe and are acceptable to use NO heparin for heparin-induced thrombocytopenia (HIT) positive patients: flush with 0.9% saline 10ml Heparin NOT needed for ‘saline only/valved’ devices Flush IMMEDIATELY post-infusion and after blood drawing Use push-pause/pulsatile flush method (see module 1 for description) CentralCentral VADVAD CareCare && Maintenance:Maintenance: HeparinHeparin To minimize risk of unintended systemic anticoagulation from frequent flushing, consider piggy-backing medications into an ordered infusion Adult ‘guideline’: recommended maximum per 24 hours for intermittent flushes should not exceed 2,000 unit heparin Pediatrics ‘guideline’: maximum heparin per 24 hours should not exceed 75 units per kg or 2,000 units in 24 hours -- Obtain order for VAD heparin flush to enable EMAR documentation “Fun fact”: heparin does NOT dissolve existing clots; it helps prevent future clots AdultAdult HeparinizationHeparinization ChartChart (per(per lumen)lumen) MGH Nursing Policies and Procedures Trove 05-03-06 Type of Catheter Routine Flushing Frequency of Flush Implanted ports: Heparin 100 units/ml; flush After completion of any infusion or blood sampling. Port-a-caths with 5 ml (500 units). Power ports When deaccessing or doing a Passports monthly flush to maintain patency if port is not in active use. Hickmans Heparin 10 units/ml; flush After completion of any (tunneled catheters) with 5 ml (50 units). infusion or blood sampling. When not in use flush at least 1-2 times a week. AdultAdult HeparinizationHeparinization ContinuedContinued Type of Catheter Routine Flushing Frequency of Flush Small Bore Tunneled Heparin 10 units/ml; flush After completion of any Central Line Catheters with 5 ml (50 units). infusion or blood sampling, at least once every 24 hours. (e.g. Bard Powerline) least once every 24 hours. Pheresis Catheters (large Heparin 1000 units/ml; instill After completion of any bore catheters used for volume of catheter (printed infusion or blood sampling. pheresis, bone marrow on each lumen) plus transplant) volume of cap (currently 0.2 When not in use, remove and ml for MaxPlus). If catheter reinstill MWF. [Note: May be confused volume not legible, contact with a Hickman or CNS or Interventional dialysis catheter.] Radiology for guidance. Heparin must be withdrawn from the lumen prior to flushing or infusing through the pheresis catheter, in order to avoid excess or inadvertent anticoagulation. AdultAdult HeparinizationHeparinization ContinuedContinued Type of Catheter Routine Flushing Frequency of Flush Multiple Lumen Heparin 10 units/ml; flush After completion of any Percutaneous Catheters with 5 ml (50 units). infusion or blood sampling, at least once every 24 hours. (non-tunneled catheters) least once every 24 hours. PICCs and power- Heparin 10 units/ml; flush After completion of any injectable PICCs (e.g. with 5 ml (50 units). infusion or blood sampling, at least once every 24 hours. Bard Power PICC) least once every 24 hours. Saline-only PICCs and Do NOT require Heparin. Flush after each use or at least every 7 days when not Valved catheters Use preservative-free Normal Saline: flush with at in use. (e.g. Vaxcel or Bard Normal Saline: flush with at least 20 ml after blood PowerPICC SOLO) Although these do not require PowerPICC SOLO) draws or discontinuing TPN; Although these do not require heparin, OK to use if needed. 10 ml after meds or for routine flush. It is essential to use push- pause technique when flushing saline-only catheters. AdultAdult HeparinizationHeparinization ContinuedContinued Type of Catheter Routine Flushing Frequency of Flush Hohn Catheters Heparin 10 units/ml; flush After completion of any with 5 ml (50 units). infusion. When not in use, flush every 7 days. Groshong Tip Catheters Do NOT require Heparin. Flush after each use or at Use preservative-free least every 7 days when not Normal Saline: flush with at in use. least 20 ml after blood draws or discontinuing TPN; draws or discontinuing TPN; Although these do not require 10 ml after meds or for heparin, OK to use if needed. routine flush. heparin, OK to use if needed. It is essential to use push- pause technique when flushing saline-only catheters. PediatricPediatric HeparinizationHeparinization ChartChart (per(per lumen)lumen) MGH Nursing Policies and Procedures Trove 05-03-06 Type of Catheter Routine Flushing Frequency of Flush Implanted ports: Adolescents: Heparin 100 After completion of any infusion or blood sampling. Port-a-caths units/ml; flush with 5 ml (500 units). Power ports When deaccessing or doing a monthly flush to maintain [Ports