Program Developed by g p y - ASCO University

Central Venous Access: An Overview

IImproving i P Practice ti Through Th h Knowledge

Program g Developed p by y Susie Mason, RN, MSN, OCN— Clinical Nurse Education Specialist, Amy S. Coghill, RN, MSN, OCN, Clinical Nurse Education Specialist Linda M. McElveen, MSN, RN, CRNI The University of North Carolina Chapel Hill.

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Objectives: At the end of this program the participant will.. • Name the 4 categories of central venous access devices • Describe their similarities and differences

Central Venous Access • Tunneled ·permanent/long-term/appropriate p g pp p for home ·placed in VIR or the OR • Non-Tunneled ·temporary/short-term/removed prior to discharge ·placed at the bedside or in VIR • PICC (Peripherally Inserted Central Catheter) ·6-8 weeks and up to a year or more ·placed at the bedside by the PICC team or in VIR • Implanted Port ·permanent/long-term ·placed in VIR or the OR

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Tunneled Catheters • Hickman ·singlei l to t multilti lumen • Bard “purple” PowerLine ·single/double lumen; 5-6 Fr. • Broviac ·single- to multilumen

Tunneled Catheters cont…….. • Apheresis/ H Hemodialysis di l i ·at least doublelumen; 11-13.5 Fr. • Groshong

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Tunneled Catheters • At UNC HealthCare all tunneled catheters th t enter t the th circulation i l ti att the th Internal Jugular vein (IJ) with the tip terminating in the Superior Vena Cava (SVC) or the Right Atrium (RA)

CVAD Tip Placement

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Tunneled Catheter

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Tunneled Catheter

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Tunneled Catheters • What are the advantages of a tunneled catheter? – Tunneling and the cuff provide protection against infection – Long Long-term term use - months to years – Patients may be discharged with these

Question #1 • Your patient needs a central line for 46 months th off TPN TPN. Of the th 4 categories, t i the best choice is: a) an epidural b) a PICC c) a purple PowerLine d) a portacath

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Rationale • a) Never! And not a central line. • b) Not the best choice for long term therapy therapy, however, if no other options PICC is a possibility. • c) Correct. The best choice for several months of therapy. The catheter is tunneled, with good protection from infection and when not connected to TPN the catheter is out of th way and the d generally ll covered db by clothing. l thi • d) Poor choice because the needle would be in place 24/7 over several months.

Non-Tunneled Catheters • Hohn ·singlei l or double-lumen d bl l ·placed in VIR • Apheresis/Hemodialysis ·at least double-lumen; 11-13.5Fr. • Arrow ·multi-lumen catheters ·placed at the bedside

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Non-Tunneled Catheters • Non-tunneled catheters are placed in the : ·Internal Internal Jugular vein (IJ) ·Subclavian vein ·Femoral vein • The catheter tip will terminate in the SVC or RA if Internal Jugular or Subclavian and in the Inferior Vena Cava if a femoral line • Non-tunneled Non tunneled catheters are inserted at the bedside or in VIR

The point where the needle enters the skin ki is i where h the th catheter th t enters t the th vein. There is NO protection from infection as with tunneling or a cuff.

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This is the Sorbaview IJ dressing; g the p preferred dressing for IJ lines.

The point where the needle enters the skin is where the catheter enters the vein. There is NO protection from infection as with tunneling or a cuff.

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Non-Tunneled Catheters • Patients should not leave the hospital with ith non-tunneled t l d catheters th t • There is NO inherent protection from infection as there is with tunneled catheters

Important points for both tunneled and non-tunneled… • Hemodialysis and apheresis catheters may be b ttunneled l d or non-tunneled, t l d depending on how long the patient needs the catheter and if the patient is expected to go home with it. • Remember…patients cannot be discharged home with non-tunneled catheters.

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Important points for both tunneled and non-tunneled.. • Only hemodialysis nurses may access h hemodialysis di l i catheters th t • Any nurse can change the dressing on a hemodialysis catheter • Treat Apheresis catheters as you would any other central line, except.. – DO NOT use for continuous infusion (heparin, (heparin insulin, vasoactive drugs) if used for apheresis

PICC • Peripherally Inserted Central Catheter -at the bedside, by the PICC team -in VIR •single-, double-, or triple-lumen • This is a non-tunneled catheter • It can be long-term, but is usually placed for 6-8 weeks of therapy.

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PICC

Question #2 • Consider the previous slide and using your best judgment judgment, in which case would a PICC be contraindicated? a) a patient with endocarditis b) a patient with scabies c) a patient needing every 6-hour Zosyn d) a patient using crutches and a wheelchair

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Rationale • a) PICC would be a good choice for a patient needing 6 to 8 weeks of IV antibiotics. • b) Annoying, but not a contraindication. • c) PICC would be a good choice. • d) Correct. A PICC is contraindicated because of the p potential p pressure from the crutches on the PICC in the axillary areas and the arm movement when using a wheelchair.

PICC • Bard PowerPICCs (purple)

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The point where the needle enters the skin is where the catheter enters the vein

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Implanted Port • Portacath • PasPort P P t • • • •

Implanted and tunneled Single- or dual-lumen g intermittent therapy py Excellent for long-term Most often placed in the right or left chest and at UNC will be tunneled into the IJ

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Single-lumen Portacath

Dual-lumen Portacath

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Implanted Port • Cross-section of a portacath • Note the well or reservoir behind the septum: ports require more flush to fill the well • Always Al access a port using a noncoring needle

Question #3 • Your patient needs a central line to receive an outpatient infusion of chemotherapy every 14 days. Her best choice is: a) a PICC b) a portacath c) an A-line d) a triple lumen non-tunneled catheter

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Rationale • a) This catheter would need daily flushing g change g at least once a and a dressing week. Not a good choice for once every 2 week therapy. • b) Correct. Absolutely the best choice. Accessed for treatment, then deaccessed. • c) Never! And not a central line. patient home with a • d)) We won’t send a p non-tunneled catheter. This is for inhospital, short-term use only.

Central Venous Access… How are they similar? • They are all CENTRAL catheters with the tip confirmed in the Superior Vena Cava/Right Atrium or if in the groin, in the Inferior Vena Cava • Always prep cap vigorously with alcohol before attaching syringe or tubing • Aseptic A ti ttechnique h i with ith d dressing i change h for all categories

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Central Venous Access… How are they different? • Tunneled are long-term, with protection from infection • Non-tunneled are short term, with no protection from infection • PICCs are placed in a peripheral vein in the arm with the tip centrally located • Ports are tunneled and implanted and have the best protection from infection

References: • Infusion Therapy in Clinical Practice Hankins et al 2nd Edition, Hankins, Edition 2001 • Guidelines for the Prevention of Intravascular Catheter-Related Infections 2002 Centers for Disease Control and Prevention • Journal of Infusion Nursing Standards of Practice, 2006

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You have completed the CVAD courseCentral Venous Access: An Overview

Congratulations

- Click HERE to end this tutorial and access the assessment and submit results to your LMS Transcript.

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