De La Salle – Health Sciences InstituteCollege of Nursing and School of Midwifery

Dasmarinas, Cavite

CENTRAL VENOUS LINES

Submitted by:Acar, Mylene

Burgos, Joyce MariCancio, Ana Krizia

Dolot, Rey IvanEncarnacion, Maurice Pam

Submitted to:Ms. Joyce Velasco

Date: July 2010CENTRAL LINE

I. Definition

A central line is also called a central venous line or a central venous catheter (CVC).

A catheter (tube) that is passed through a vein to end up in the thoracic(chest)

portion of the vena cava (the large vein returning blood to the heart) or in the right

atrium of the heart.

A central line is a catheter placed into a large vein. Most commonly used veins are

the internal jugular vein, the subclavian vein and the femoral vein.

A central line saves having to have frequent small injections or "drips" placed in the

arms. A central line may also allow a patient to have medicine or fluids at home

instead or in the hospital.

The central line may be inserted for the short term or long term. There are two types

of long term central lines: the cuffed or tunnelled line and the reservoir long line that

ends in a rubber bulb or reservoir.

The possible complications of a central line include air in the chest (pneumothorax)

due to a punctured lung, bleeding in the chest (hemothorax), fluid in the chest

(hydrothorax), bleeding into or under the skin (hematoma) and infection. If the line

becomes disconnected, air may enter the blood and cause problems with breathing

or a stroke.

II. Description and Common Features

A central line is a long, hollow tube made from silicone rubber. They are also called

skin-tunnelled central venous catheters. Examples of some of the makes that are

used are Hickman® or Groshong®.

The central line is inserted (tunnelled) under the skin of your chest into a vein. The

tip of the tube sits in a large vein just above your heart.

The space in the middle of the tube is called the lumen. Sometimes the tube has two

or three lumens. This allows different treatments to be given at the same time.

(Dependent on its use, the catheter is monoluminal, biluminal or triluminal,

dependent on the actual number of tubes - 1, 2 and 3 respectively.)

The catheter is usually held in place by a suture and an occlusive plaster.

Regular flushing with saline or a heparin-containing solution keeps the line patent

and prevents infection.

At the end of the tube outside the body each lumen has a special cap to which a drip

line or syringe can be attached.

Sometimes there is also a clamp to keep the tube closed when it is not being used.

Common Features

   Central Venous Catheter reduces the risk and vascular trauma due it

specially formulated and biocompatible Polyurethane material which provides

strength during insertion and also softens at body temperature to conform to the

body tissue

   Soft Flexible J-Tip Guide wire provides good torque to ensure firm insertion

and also prevents vessel perforation

     Specially designed soft & beveled tip for smooth & easy insertion of catheter

         Clear and definite marking facilitates correct placement of catheter tip 

         Radio-opaque Catheter

         Individually tray packed

         Also available with the option of Guided Syringe or T-Type Introducer

         Tube Length available : 160-200 mm, 300 mm 

Complete set of CVC kit consists of :

Indwelling catheterCatheter holderCatheter holder clampExtension line clamp

Injection capIntroducer needleJ-Tip guide wireLuer lock syringeScalpelVessel dilator

INDWELLING CATHETER

GUIDE WIRE NEEDLE DILATOR SYRINGE

Description O.D. (FR) / Ga (I.D.)

Length(  mm )

Diameter O.D.( inch / mm )

Length( cm / mm )

O.D. (FR) /Length ( mm )

 Single Lumen    3061

   5 FR / 16 G (D)

1600.032 / 0.81

45 / 450

18 G6 Fr / 100 mm

5 cc200 45 / 450

300 60 / 700

 Double Lumen 3062

   7 FR / 16 G (P)   - 16 G (D)

1600.032 / 0.81

45 / 450

18 G8 Fr / 100 mm

5 cc200 45 / 450

300 60 / 700

 Triple Lumen 3063

   7 FR / 18 G (P)   / 16 G (D)    / 18 G (M)

160

0.032 / 0.81

45 / 450

18 G8 Fr / 100 mm

5 cc200 45 / 450

300 60 / 700

http://www.suru.com/cvc.htm

III. Uses

1. A central line can be used to give you treatments such as chemotherapy , antibiotics

and intravenous fluids.

2. It can also be used to take samples of your blood for testing.

3. Central lines can also be used to give liquid food into the vein if your digestive

system is not able to cope with food for any reason.

4. A central line allows concentrated solutions to be infused with less risk of

complications.

5. It permits monitoring of special blood pressures including the central venous

pressure, the pulmonary artery pressure, and the pulmonary capillary wedge

pressures.

6. The central line can be used for the estimation of cardiac output and vascular

resistance. The near end of the catheter may also be connected to a chamber for

injections given over periods of months.

You can go home with the central line in place and it can be left in for weeks or months.

This makes it possible for you to have your treatment without having to have needles

frequently put into your veins. This may be very helpful if doctors and nurses find it

difficult to get needles into your veins, or if the walls of your veins have been hardened

by previous chemotherapy treatment.

IV. Indications and Containdications

Indication

Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid

balance

Long-term intravenous antibiotics

Long-term parenteral nutrition especially in chronically ill patients

Long-term pain medications

Drugs that are prone to cause phlebitis in peripheral veins (caustic), such as:

Calcium chloride

Chemotherapy

Hypertonic saline

Potassium chloride

Amiodarone

Plasmapheresis

Dialysis

Frequent blood draws

Frequent or persistent requirement for intravenous access

Need for intravenous therapy when peripheral venous access is impossible

Blood

Medication

Rehydration

Central venous catheters usually remain in place for a longer period of time,

especially when the reason for their use is longstanding (such astotal parenteral

nutrition in a chronically ill patient). For such indications, a Hickman line, a PICC

line or a portacath may be considered because of their smaller infection risk. Sterile

technique is highly important here, as a line may serve as a porte d'entrée (place of

entry) for pathogenic organisms, and the line itself may become infected with

organisms such as Staphylococcus aureus and coagulase-negative Staphylococci.

Central venous pressure is considered a direct measurement of the blood pressure in

the right atrium and vena cava. It is acquired by threading a central venous catheter

(subclavian double lumen central line shown) into any of several large veins. It is

threaded so that the tip of the catheter rests in the lower third of the superior vena cava.

The pressure monitoring assembly is attached to the distal port of a multilumen central

vein catheter. 

The CVP catheter is an important tool used to assess right ventricular function and

systemic fluid status.

Normal CVP is 2-6 mm Hg.

CVP is elevated by :

o overhydration which increases venous return

o heart failure or PA stenosis which limit venous outflow and lead to venous

congestion

o positive pressure breathing, straining,

CVP decreases with:

o hypovolemic shock from hemorrhage, fluid shift, dehydration

o negative pressure breathing which occurs when the patient demonstrates

retractions or mechanical negative pressure which is sometimes used for

high spinal cord injuries.

The CVP catheter is also an important treatment tool which allows for:

Rapid infusion

Infusion of hypertonic solutions and medications that could damage veins

Serial venous blood assessment

Parenteral nutrition   (PN) is feeding a person intravenously, bypassing the usual process

of eating and digestion. The person receives nutritional formulas

containing salts, glucose, amino acids, lipids and added vitamins. It is called total

parenteral nutrition (TPN) when no food is given by other routes.

Phlebitis   is an inflammation of a vein, usually in the legs. When phlebitis is associated

with the formation of blood clots (thrombosis), usually in the deep veins of the legs, the

condition is called thrombophlebitis. These clots can travel to the lungs,

causing pulmonary embolisms which can be fatal.

Chemotherapy is the use of chemical substances to treat disease. In its modern-day

use, it refers almost exclusively to cytostatic drugs used to treat cancer. In its non-

oncological use, the term may also refer to antibiotics (antibacterial chemotherapy).

Calcium chloride is an irritant, particularly on moist skin. Dry calcium chloride

reacts exothermically when exposed to water. Burns can result in the mouth

and esophagus if humans or other animals ingest dry calcium chloride pellets. Small

children are more susceptible than adults (who generally have had experience trying to

eat hot food, and can react accordingly) so calcium chloride pellets should be kept out

of their reach.

Hypertonic saline is used in treating hyponatremia and cerebral edema. Due to

hypertonicity, administration may result in phlebitis and tissue necrosis. As such,

concentrations greater than 2% NaCl should only be administered via a central venous

catheter. It is commonly available in two strengths:

3% NaCl has 513 mEq/L of Na and Cl.

5% NaCl has 856 mEq/L of Na and Cl.

Potassium Chloride may cause pain and thrombophlebitis if administered in high

concentration into small veins.

IV intermittent - for urgent potassium replacement:

Peripherally:

o Maximum 20 mEq/250 mL administered over 1 hour

Central line:

o General Nursing Units: Maximum 20 mEq/100 mL over 1 hour;    

o Cardiac Sciences (C10AB, CD) may administer maximum of 20

mEq/50mL over 1 hour

o Critical/Special Care Areas: Maximum of 40 mEq/100 mL over 1 hour

IV infusion:

Peripheral Line: Usual concentration: 20-40 mEq/L; Maximum: 80 mEq/L, infused

at a maximum rate of 10 mEq/hour

Central Line: Usual concentration: 20-60 mEq/L; infused at a maximum rate of 20

mEq/hour

Amiodarone belongs to a class of drugs called Vaughan-Williams Class IIIantiarrhythmic

agent. It is used in the treatment of a wide range of cardiac tachyarhthmias, including

both ventricular and supraventricular (atrial) arrhythmias. The chemical name for

amiodarone is 2-butyl-3-benzofuranyl 4--3,5-diiodophenyl ketone hydrochloride.

Plasmapheresis   is the removal, treatment, and return of (components of) blood

plasma from blood circulation. It is thus an extracorporeal therapy. The method can also

be used to collect plasma for further manufacturing into a variety of medications. During

plasmapheresis, blood is initially taken out of the body through a needle or previously

implanted catheter. Plasma is then removed from the blood by a cell separator. 

D ialysis   (from Greek "dialusis", meaning dissolution, "dia", meaning through, and "lysis",

meaning loosening) is primarily used to provide an artificial replacement for lost kidney

function in people with renal failure. A central line is necessary when you need drugs

given through your veins over a long period of time, or when you need kidney

dialysis. In these cases, a central line is easier and less painful than having needles put

in your veins each time you need therapy.

Blood   is a circulating tissue composed of fluid plasma and cells (red blood cells, white

blood cells, platelets). Medical terms related to blood often begin in hemo- or

hemato- (BE: haemo- and haemato-) from the Greek word "haima" for "blood". The

main function of blood is to supply nutrients (oxygen, glucose) and constitutional

elements to tissues and to remove waste products (such as carbon dioxide and lactic

acid). Blood also enables cells (leukocytes, abnormal tumor cells) and different

substances (amino acids, lipids, hormones) to be transported between tissues and

organs. Problems with blood composition or circulation can lead to downstream tissue

dysfunction.

M edication  is a licensed drug taken to cure or reduce symptoms of an illness or medical

condition. Medications are generally divided into two groups -- over the counter (OTC)

medications, which are available in pharmacies and supermarkets without special

restrictions, and Prescription only medicines (POM), which must be prescribed by

a physician. Most OTC medication is generally considered to be safe enough that most

persons will not hurt themselves accidentally by taking it as instructed. However, the

precise distinction between OTC and prescription depends on the legal jurisdiction.

Medications are typically produced by pharmaceutical companies and are

oftenpatented. Those that are not patented are called generic drugs.

Rehydration   is the replenishment of water and electrolytes lost through dehydration. It

can be performed by mouth (oral rehydration) or by adding fluid and electrolytes directly

into the blood stream (intravenous rehydration). As oral rehydration is less painful, less

invasive, less expensive, and easier to provide, it is the treatment of choice for

mild dehydration from infectious gastroenteritis. Because severe dehydration can

rapidly cause permanent injury or even death, intravenous rehydration is the initial

treatment of choice for that condition.

http://en.wikipedia.org/wiki/Central_venous_catheter

http://www.spiritus-temporis.com/central-line/indications-and-uses.html

Contraindications

Uncooperative patient

Uncorrected bleeding diathesis

Skin infection over the puncture site

Distortion of anatomic landmarks from any reason

Pneumothorax or hemothorax on the contralateral side

Positive end-expiratory pressure (PEEP) mechanical ventilation

Only one functioning lung

http://note3.blogspot.com/2004/02/central-line-placement-procedure-guide.html

V. Types

1. Non - Tunneled Central Catheters

Non Tunneled central catheters are used for short-term(less than 6 weeks) IV

therapy in acute care, long-term care and home care settings. The physician inserts

these catheters. Examples of non-tunneled catheters are Vas Cath, percutaneous

subclavian Arrow and Hohn catheters. The subclavian vein is the most common vessel

used, because the subclavian area provides stable insertion site to which the catheter

can be anchored, allows the patient freedom of movement and provides easy access to

the dressing site. The jugular vein should only be used as a last resort and then only for

1 to 2 days. The 16-gauge distal lumen can be used to infuse blood or other viscous

fluids. The 18-gauge middle lumen is reserved to PN infusion. The 18-gauge proximal

port can be used for administration of blood or medications. A port not being used for

fluid administration can be used for obtaining blood specimens if indicated.

If a single-lumen central catheter is used to administer PN, various restrictions

apply. Blood cannot be drawn from the catheter and transfusions of blood products

cannot be given through the main line, because red blood cells may coat the lumen of

the catheter, thereby reducing the flow of the nutritional solution. Medications also

cannot be administered through it, because it may be incompatible with the components

of the nutritional solution (insulin is an exception). If medications must be given, they

must be infused through a separate peripheral IV line, not by piggyback into the PN line.

Insertion

The procedure is explained so that the patient understands the importance of not

touching the catheter insertion site and is aware of what to expect during the insertion

procedure. The patient is placed in supine in the Trendelenburg position (to produce

dilation of neck and shoulder vessels, which makes entry easier and prevents air

embolus). The area is shaved if necessary, and the skin is prepared with acetone and

alcohol to remove surface oils. Final skin preparation includes cleaning with tincture of

2% iodine or chlorhexidine. To afford maximal accuracy in the placement of the

catheter, the patient is instructed to turn the head way from the site of venipuncture and

to remain motionless while the catheter is inserted and the wound is dressed. The

preferred insertion route is the subclavian vein, which leads into the superior vena cava.

The external jugular route can be used, but usually only in emergency situations.

Because a non-tunneled central catheter is always a potential source of serious

infection, the insertion site should be changed every 4 to 6 weeks or as recommended.

Full-length sterile drapes are applied. Procaine or lidocaine is injected to

anesthetize the skin and underlying tissues. The target area is the inferior border at the

midpoint of the clavicle. A large-bore needle on a syringe is inserted and moved parallel

to and beneath the clavicle until it enters the vein. The syringe is then detached and a

radiopaque wire is inserted through the needle into the vein. The catheter us then

advanced over the wire, the needle is withdrawn, and the hub of the catheter is attached

to the IV tubing. Until the syringe is detached from the needle and the catheter is

inserted, the patient may be asked to perform VALSALVAmaneuver. (The patient is

instructed to take a deep breath, hold it, and bear downwith mouth closed.) The

Valsalva maneuver is performed to produce a positive phase in central venous

pressure, thereby lessening the possibility of air being drawn into the circulatory system.

The physician sutures the catheter to the skin to avoid inadvertent removal.

The catheter insertion site is swabbed with either tincture of 2% iodine or a

chlorhexidine solution. A gauze or transparent dressing is applied using strict sterile

technique. An isotonic IV solution, such as dextrose 5% in water is administered to keep

the vein patent. The position of the tip of the catheter is checked with x-ray or

fluoroscopy to confirm its location in the superior vena cava and to rule out

pneumothorax resulting from inadvertent puncture of the pleura. Once the catheter’s

position is confirmed, the prescribed PN solution is started. The initial rate of infusion is

usually 50ml/hr and the rate is gradually increased to the maintenance rate or

predetermined dose. An infusion pump is always used for administration of PN.

And injection site cap is attached to the end of each central catheter lumen,

creating a closed system. IV infusion tubing is connected to the insertion site cap of the

central catheter with a threaded needleless adapter or Luer-lok device. Each lumen is

labelled according to the location. To ensure patency, all lumen are flushed with diluted

heparin flush initially, daily when not in use, after each intermittent infusion, after blood

drawing, and whenever an infusion is disconnected. Force is never used to flush the

catheter. If resistance is met, aspiration may restore lumen patency; if this is not

effective, the physician is notified. Low-dose tissue plasminogen activator (altepalse)

may be prescribed to dissolve clot or fibrin sheath. If attempts to clear the lumen are

ineffective, the lumen is labelled as “clotted off” and not used again.

Care of Non Tunneled Central Catheter

1. Hand washing: always wash your hands with soap and water before touching the

central line or the area around it.

2. Activity guidelines: do not go swimming.

3. Central line may need to be flushed: it can be saline, heparin or both; flushing is

done to help prevent the catheter from getting blocked. It also helps to prevents

mixing of medicines with each other in the tubing.

Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11 th Edition) Volume 1.

Lippincott William and Wilkins.

2. Peripherally Inserted Central Catheter

- Used for intermediate long term care IV therapy that could last for several days up to

months.

- Done in hospital or home setting.

- It is inserted at Basilic and Cephalic vein through the antecubital space.

- The catheter is threaded to a designed location depending on the type of solution to

be infused. (E.g. Superior vena cava for parenteral nutrition)

- Solutions that can be infused through this method include total parenteral nutrition,

chemotherapy regimens and extended antibiotic therapy.

- Taking of blood samples and blood pressure are contraindicated.

- Length of the catheter ranges from 30-65cm.

3. Tunneled Central Catheter

- It is used for long term care and may remain in place for years.

- The catheters have cuffed and can have single or double lumens. ( E.g. Hickman,

Groshong, Permacath)

- Inserted to vein at one location tunneled under the skin to a separate exit where it

emerges from underneath the skin. It is held in place by a Dacron cuff, just

underneath the skin at the exit site. Exit is located in chest making access ports less

visible than if they were directly protruded from the neck.

- Passing of the catheter under the skin prevents infection and provides stability.

The Hickman catheter

It is softer than a simple triple-lumen catheter, and is usually inserted in an

operating room. The actual access to the subclavian vein is still by puncture under the

clavicle, but the distal end of the catheter is pulled under the skin for 2-4 inches and

comes out of the chest close to the nipple. This creates a "tunnel" which decreases the

risk of infection. These catheters can stay in place for weeks to months.

The Groshong catheter

It is very similar to the Hickman catheter, but has a valve at the tip of the catheter

which makes it unnecessary to leave a high concentration of heparin in the catheter

(see below). The Broviac catheter is also similar to the Hickman catheter, but is of

smaller size. This catheter is mostly used for pediatric patients

4. Implanted Ports

- Implantable Ports are catheters which are inserted completely under the skin.

- The distal end of the catheter is formed by a small metal "drum" or reservoir, which

has on one side a membrane for needle access. This drum is surgically placed

under the skin, just below the clavicle, with the membrane immediately below the

skin. The catheter runs from the drum into the subclavian vein. Access is always

with a special needle that is pushed through the skin and the membrane into the

reservoir inside the drum. Such ports come in different sizes, and can have either

one or two lumens. Since the entire catheter is under the skin, the risk of infection is

smaller than with external catheter 

VI. INSERTION AND REMOVAL OF CENTRAL CATHETERS

INSERTION OF CENTRAL CATHETERS

Prior to the procedure

Adhere to institutional Policy and Procedure.

Obtain history and assess the patient.

Explain the procedure to the patient, include:

local anesthetic

trendelenberg positioning (to produce dilation of neck and shoulder

vessels, which makes entry easier and prevents air embolus).

turn the head away from the site of venipuncture and to remain

motionless while the catheter is inserted and the wound is dressed for

maximal accuracy

draping

limit movement

need to maintain sterile field.

post procedure chest X-ray

Obtain the catheter size, style and length ordered.

Obtain supplies:

Masks

Sterile gloves

Line insertion kit

Heparin flush per policy

Position patient supine on bed capable of trendelenberg position

Prepare for post procedure chest X-ray or fluoroscopy

1. Nontunneled Central Catheters

The area is shaved if necessary, and the skin

is prepared with acetone and alcohol to

remove surface oils. Final skin preparation

includes cleaning with tincture of 2% iodine

or chlorhexidine.

The preferred insertion route is the

subclavian vein, which leads into the superior

vena cava. The external jugular route can be

used, but usually only in emergency

situations.

Full length sterile drapes are applied.

Procaine or lidocaine is injected to

anesthetize the skin and underlying tissues.

The target area is the inferior border at the

midpoint of the clavicle.

A large-bore needle on a syringe is inserted

and moved parallel to and beneath the

clavicle until it enters the vein.

The syringe is then detached and a radiopaque

wire is inserted through the needle into the

vein. The catheter is then advanced over the

wire, the needle is withdrawn, and the hub of

the catheter is attached to the IV tubing. The

physician sutures the catheter to the skin to

avoid inadvertent removal.

The catheter insertion site is swabbed with either tincture

of 2% iodine or a chlorhexedine solution. A gauze or

transparent dressing is applied using strict sterile

technique. An isotonic IV solution, such as dextrose 5%

in water (D5W), is administered to keep the vein patent.

The position of the tip of the catheter is checked with x-

ray or fluoroscopy to confirm its location in the superior

vena cava and to rule out pneumothorax resulting from

inadvertent puncture of the pleura. Once the catheter’s

position is confirmed, the prescribed parenteral nutrition

solution is started. The initial rate of infusion is usually 50 mL/hour, and the rate is

gradually increased to the maintenance rate or predetermined dose (eg, 100 to 125

mL/hour). An infusion pump is always used for administration of parenteral nutrition.

An injection site cap is attached at the end of each

central catheter with a threaded needleless adapter or

Luer-Lok device. Each lumen is labeled according to

location (proximal, middle, distal). To ensure patency, all

lumens are flushed with a diluted heparin flush initially,

daily when not in use, after each intermittent infusion,

after blood drawing, and whenever an infusion is disconnected. Force is never used to

flush the catheter. If resistance is met, aspiration may restore lumen patency; if this is

not effective, the physician is notified. Low-dose plasminogen activator (alteplase) may

be prescribed to dissolve a clot or fibrin sheath. If attempts to clear the lumen are

ineffective, the lumen is labeled as “clotted off” and not used again.

Because a nontunneled central catheter is always a potential source of infection, the

insertion site should be changed every 4 to 6 weeks, or as recommended by the latest

CDC guidelines.

2. Peripherally Inserted Central Catheters

Basilic or cephalic vein inserted through the antecubital space, and catheter is threaded

to a designated location, depending on the type of solution to be infused.

The insertable portion of a PICC varies from 35 to 60 centimeters in length, that being

adequate to reach the desired tip position in most patients. Some lines are designed to

be trimmed to the desired length before insertion. Others are simply inserted to the

needed depth with the excess left outside. As supplied, the line has a guide wire inside.

This wire is provided to stiffen the (otherwise very flexible) line so it can be pushed

through the veins. The wire is removed and discarded after insertion.

3. Tunneled Central Catheters

These catheters are inserted surgically. They are threaded under the skin to the

subclavian vein and the distal and of the catheter is advanced to the superior vena

cave.

Your neck will be checked for a suitable

vein using a small ultrasound machine.

The area where the line is to be inserted

is cleaned with an antiseptic solution.

A local anaesthetic is used the numb the

area. Pain would not be felt during the

insertion, but a bit of soreness is usually

felt for a few days afterwards.

A small cut is made in the skin near the clavicle and the tip of the tube is threaded into a

large vein. This is known as the insertion site. The tube is then pushed under the skin to

reach the exit site.

Chest x-ray is ordered to make sure that the tube is put in the right place.

The position of the exit site will vary from person to person. The nurse or the physician

can inform the patient where on the chest the exit site is likely to be.

When the tube has been put in, dressings are applied aseptically to cover the insertion

and exit sites. For a few days, the patient may feel pain or discomfort under the skin

where the tube has been tunnelled. A mild painkiller such as paracetamol will help to

ease this.

4. Implanted Ports

Instead of exiting from the skin, the end of the catheter is placed in a subcutaneous

pocket, either on the anterior chest wall or on the forearm.

The port is surgically implanted beneath the

skin, and generally in the chest region. The

incision is made halfway between the clavicle

and nipple on either the left or right side of the

chest. The right side of the chest is generally

preferred since the vein curves down more

directly to the superior vena cava. The surgeon

makes the final decision about the site for

implantation based on skin condition, presence

of a pacemaker, and taking into account other

medical conditions that would contra-indicate

the use of a particular site. An approximate 5-

cm incision in the skin is made at the selected

site. A “kangaroo” pocket is created approximately two inches away from the incision

line and 0.5-cm to 2.0 cm deep into which the portal body is placed. The pocket is

located away from the incision line in order to avoid rupturing the incision with

subsequent accessing of the port. The implanted port is placed in this pocket and

sutured in place to the underlying tissue.

The suturing should be secure enough so that the implanted port won’t loosen with

frequent accessing and manipulation of the port. The underlying tissue should be firm in

order to provide support to the implanted port for accessing and de-accessing. The

catheter is connected to the portal body at the shoulder of the implanted port Catheters

separate from the portal body are pushed over the barb and the catheter locked in place

with a radiopaque ring. The catheter is then threaded subcutaneously from a point near

the clavicle to meet with the portal body. The catheter tip is advanced into the

subclavian vein and terminated in the superior vena cava/atrial junction. It takes

approximately two weeks for the body to establish a “healed in tract” for the tunneled

catheter.

This procedure takes from one-half to one-hour and generally a local anesthesia is

used.

Other sites used for the placement of implanted ports are in the abdominal cavity with

the tip of the catheter tunneled into the inferior vena cava. The breast may also be used

for implanted port placement in female patients. These sites provide less stability to the

port when accessed than does the chest location.

VII. REMOVAL OF CENTRAL CATHETERS

1. Nontunneled Central CathetersAND Peripherally Inserted Central Catheters

A nurse will usually does this in an outpatient department. It will be gently pulled out.

This is a painless procedure that takes only a few minutes.

2. Tunneled Central Catheters

Patient will lie on a bed. The chest is cleaned with antiseptic. The area around the cuff is

numbed with local anaesthetic. A small cut is made to gently release the cuff and the line is then

removed slowly. This can feel uncomfortable, but it should not be painful.

A dressing will be put over the exit site and patient will be asked to remain lying down (for about

10 minutes) until it is certain that there is no bleeding.

3. Implanted Ports

This is usually done by a doctor who will use a local anaesthetic to numb the area. Sometimes

the port will be removed under a general anaesthetic.

The doctor will make a small incision over the site of the port and remove it. The catheter will be

pulled out of the vein. The wound is then stitched and covered with a small dressing.

Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11th Edition).

Lippincott William and Wilkins.

http://nursinglink.monster.com/training/articles/302-the-use-and-maintenance-of-

implanted-port-vascular-access-devices

http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/

Treatmenttypes/Chemotherapy/Linesports/Implantableport.aspx

http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/

Treatmenttypes/Chemotherapy/Linesports/PICCline.aspx

http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/

Treatmenttypes/Chemotherapy/Linesports/Centrallines.aspx

VIII. Care of Central Venous Catheter

• Do not let the CVC exit site get wet until it is well healed. Client may shower 72 hours

after the catheter has been inserted. When bathing or showering, cover the site with

waterproof material, such as household plastic wrap, taped over the dressing and

injection caps.

• Do not submerge the CVC site or caps below the level of water in a bathtub, hot tub,

or swimming pool.

• Store CVC supplies in a clean, dry place such as a shelf in a closet or a drawer.

• Always clean the work area with alcohol and let it to dry completely before setting up

the supplies or cover the area with clean paper towels.

• Use only sterile supplies. Open all packages carefully without touching the contents.

Handle dressings only at the edges.

• Never touch the open end of the CVC when the cap has been removed.

• Never touch the end of the needleless cannula or the end of the open syringe. If this

happens accidentally, use a new cannula or syringe.

• Never use scissors, pins, or sharp objects near the CVC or other tubing. The catheter

could be damaged easily.

• If the catheter has a clamp, keep it clamped when not in use. Some CVCs show where

the clamp must be placed. If CVC does not show the clamp location, ask nurse to show

where to clamp.

• Remember to wash hands thoroughly before and after working with the CVC.

Changing the CVC dressing

The CVC dressing is changed every 7 days if you are using a transparent

dressing. Change it every 48 hours if using gauze or Telfa island dressing and tape. If

the dressing becomes wet or loose, change it even if it is not the normal time to change

it. A nurse will give specific instructions the type of dressing.

Flushing of catheter with a clamp

Some CVCs have separate tubes. Each tube is called a lumen. Each lumen of

the CVC needs to be flushed regularly to keep it clear of backed-up blood. If you have

more than 1 lumen, it is helpful to have a routine for flushing lumens in the same order

each time. For instance, you might always flush the red one first, then the white, then

blue. You will flush each lumen of the CVC once a day using 3 cc of heparin solution

(100 units heparin/cc), unless you have been instructed differently.

Flushing of Groshong catheter

Groshong catheters are flushed once a week or when the catheter is used. The

lumens are flushed using 10 cc of saline solution on the same day of each week.

Heparin is not used because of the special construction of the Groshong catheter.

Central venous catheter cap changes

The injection cap on each lumen of your CVC is changed every 5 to 7 days. Change a

cap any time it is leaking.

Problems encountered:

Accidental removal of the CVC from the

chest

Apply pressure to the exit site and chest

area above it with a gauze dressing or

clean washcloth. Call the immediately.

Accidental removal of injection cap

Make sure that the CVC is clamped. Clean

the outside threaded area of the lumen

with an alcohol wipe for at least 30

seconds. Place a new cap securely into

the open end. If you do not have a new

cap, wrap the end of the lumen with sterile

gauze until you can get a cap. Flush

catheter following the usual steps.

Damage to the CVC, such as a hole or

crack in the tubing

Immediately clamp the CVC between the

hole and chest. If necessary, pinch or fold

it over to clamp it. Cover the hole or crack

with sterile gauze.

Difficulty flushing the catheter

Make sure the CVC is unclamped. Change

position by raising the arms, lying down,

sitting up more straight, coughing, or

taking a deep breath. If you still cannot

flush it, stop using the catheter and call the

doctor immediately.

Loose suture at exit site Tape the CVC to the skin. Notify physician.

IX. Possible complications of Central Lines

Infection

It is possible for an infection to develop either inside the central line or around the exit

site. Watch out for:

the exit site when it becomes red or swollen or painful

discolored fluid coming from it

development of fever or chills

swelling of the face, neck, chest, or arm on the side where your catheter is inserted

displacement or lengthening of the catheter

Client will be given antibiotics, but if these do not clear the infection from the line it may

have to be removed.

Blood clots

It is possible for a blood clot (thrombosis) to form in the vein at the tip of the line. If a clot

does form, client will be given some medication to dissolve the clot and line may have to

be removed.

Arrhythmias

Arrhythmia may occur during the insertion process when the wire comes in contact with

the endocardium. It typically resolved when the wire is pulled back.

Pneumothorax

Central line insertion outweighs the risk for pneumothorax. It is for central lines placed in

the chest. No air must be allowed to get into the central line. The clamps should always

be closed when the line is not in use. The line must not be left unclamped when the

caps (bungs which are at each end of it and stop air from passing through it) are not in

place. Groshong lines do not have clamps; they have a special valve inside the line

instead.

Complications of Parenteral Nutrition

Complications:

Pneumothorax

Cause:

- Improper catheter

placement and inadvertent

puncture of the pleura

Treatment:

Place patient in

fowler’s position

Offer reassurance

Monitor vital signs

Prepare for

thoracentesis or

chest tube insertion

Air embolism - Disconnected tubing

-Blocked segment of

vascular system

Replace tubing

immediately and

notify physician

Turn patient on left

side place in the

head-low position.

Notify physician.

Clotted catheter -Inadequate/infrequent

heparin flushes

Administer heparin

flush in unused lines

twice a day

Catheter displacement and

contamination

-Excessive movement Stop the infusion and

notify the physician

Sepsis -Separation of dressing

-Separation of tubing and

contamination

Monitor vital signs

every 4 hours

Reinforce dressing

quickly using aseptic

technique

Hyperglycemia -Glucose intolerance Administer insulin as

orderly

Fluid overload -Fluid infusing rapidly Decrease infusion

rate

Monitor vital signs

Notify physician

Rebound hypoglycemia -Feedings stopped too

abruptly

Monitor for

symptoms

(weakness, tremors,

diaphoresis,

headache, hunger

and apprehension)

http://www.upmc.com/HealthAtoZ/patienteducation/Documents/CVC.pdf

http://en.wikipedia.org/wiki/Central_venous_catheter

Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11 th Edition) Volume 1.

Lippincott William and Wilkins.

 ♥ In God We Trust. ♥