Essentials of vascular access
- 1. Vascular Access: An all encompassing approach
- 2. 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
- 3. 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
- 4. 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
- 5. 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
- 6. 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
- 7. 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
- 8. 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
- 9. 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
- 10. 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
- 11. 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
- 12. 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.
- 13. Central line dressing changes Supplies – A CVC dressing change kit – A Stat Lock if changing a PICC/ midline dressing – Non sterile gloves
- 14. Steps for CVC dressing changes 1) Anchor catheter to prevent pulling of catheter 2) Wash hands open kit and don mask 3) Wearing non-sterile gloves remove old dressing carefully as to not dislodge catheter • Do not touch insertion site with non-sterile gloves 1) Once old dressing removed discard soiled gloves and don sterile gloves inspect site for CVC complications 2) If there is a Stat lock remove using alcohol carefully as not to dislodge catheter 3) Cleanse area with chlorhexidine gluconate solution use scrubbing back and forth action for 30seconds 4) Allow solution to dry for 2 min do not fan area 5) 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 1) Apply tegaderm dressing and date and time dressing
- 16. 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
- 17. 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
- 18. 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
- 20. 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
- 21. 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
- 22. 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
- 23. Demonstration of Blood Drawing techniques from CVC
- 24. 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.
- 25. 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
- 27. 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
- 28. 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
- 29. 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
- 30. 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
- 31. Peripheral IV’s
- 32. Peripheral IV Insertion Veins of the arm – Cephalic vein – Basilic vein – Medial veins – Accessory cephalic Veins of hand – Metacarpals – Dorsal venous arch
- 33. 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 inSmallest Gauge device possible in the Largest vein possible tothe Largest vein possible to accommodate the prescribedaccommodate the prescribed therapytherapy The Larger the device the higher the risk for Mechanical phlebitis
- 34. 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
- 35. 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
- 36. Practice locating veins and insertions
- 37. 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
- 38. 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 whenAn incident report must be filled out when there is any IV complicationsthere is any IV complications
- 39. Before and After the IV
- 41. Compartment syndrome caused by an IV
- 42. After one week
- 43. 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
- 44. 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
Editor's Notes
- #5: The Intima is the first layer to show S/S of phlebitis which is pain The Metacarpals and the Dorsal venous arch are hard to visualize with ultrasound
- #38: These are the most common
- #39: Yes an incident report should be completed for a complication caused by a PIV because? INFILTRATIONS- Wrong route, not the intended route of therapy,