Your Mission…. Prevention and Early Detection!!!!! Quality Improvement Evidence-based practice...
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Your Mission….
Prevention and Early Detection!!!!!
Quality Improvement
Evidence-based practice
Teamwork and Collaboration
Safety “minimize risk of harm to patients and
providers through both system effectiveness and individual performance”
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Indications
Long-termCaustic medsTPN (dextrose content > 10%)Monitor RA pressuresDialysisMultiple therapiesNo peripheral accessFrequent blood sampling
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What’s in a Name?
Central Venous Access Device (CVAD)CVCCentral lineBy type (percutaneous)TLC (triple lumen catheter), PICC
By sitesubclavian, jugular, femoral
By brand name (tunneled)Broviac, Hickman, Groshong, Mediport
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What’s the Difference?
Similarities
Tip of catheter in a “central” vein:• Superior vena
cava
Differences
How/where it is inserted
Length of stay
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Method 1: Percutaneous
Needle stick, through skin, directly into vein.Central (7 days-Phillips)PICC (> 7 days to several months)
Single, double, or triple lumen
Triple: proximal, medial, distal ports
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PICC linePeripherally Inserted Central Catheter
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Tunneled
Surgical procedure
Very long-term
Exit site: chest or abdominal wall
Examples:HickmanGroshong Implanted port (medi-port)
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CVAD Insertion
Supplies : Check P&P
tray
antiseptic solution
Dressing material
CONSENT
10 cc Syringes w/ NS
Needleless caps
“time out” check list
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Patient Teaching r/t insertion
Purpose
Position: flat, Trendelenberg
keep hands down
face covered
turn head away
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Complications of CVAD
Pneumothorax
Malposition
SVC syndrome
Occlusions
Infection
Air Embolism
Unintentional disruption
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Central Venous Catheter Complications — Pneumothorax, Hemothorax, Chylothorax
CauseDuring insertion of CVC, introducer may
cause traumaPneumothorax (collection of air in the pleural
space due to trauma to lung)Hemothorax (collection of blood in pleural
cavity)Chylothorax (transection of the thoracic duct
causes lymph fluid to enter the pleural cavity)
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Central Venous Catheter Complications: Pneumothorax
Treatment early detection: CXR after insertionOxygen Monitor vital signsPressure should be applied over the vein
entry siteRemove the catheterChest tube if appropriate
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Obstruction – Prevention is Key
Positive Pressure Displacement device
Flush unused ports per protocol
‘Push-Pause’ technique
Check solution for precipitates
Filter if indicated
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Flushing a CVAD
10 mL syringe or larger
Aspirate for blood return before flushing (INS,2006)
SAS or SASH (per hospital protocol) Groshong Catheter – saline only
“push – pause” techniqueQ 12 or 24 hours – per protocol
Positive pressure caps flush, remove syringe, clamp
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Infection
CRBSI
Exit site infection
Catheter tract infection
Septic thrombophlebitis
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Central Venous Catheter Complications: Catheter Related Blood Stream Infection
(CRBSI)
CauseBacteria or fungi in a patient who has a
intravascular device with positive blood culture
All BSIs that cannot reasonably be linked to a site of local infection are attributed to CVC
BiofilmContamination
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Central Venous Catheter Complications:CRBSI (continued)
Prevention (National Patient Safety Goals)Strict sterile technique Implementation of bundle approachTunneling and subcutaneous cuffsAntiseptic-impregnated dressingColonization-resistant polymersContamination-resistant hubsLuminal antimicrobial flush/lock solutionsGood hand hygieneFrequent site assessment
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CR-BSI “bundle”
Hand hygiene
Maximum barrier precautions “time out” during insertion prn
Chlorhexidine gluconate site disinfection
Optimal catheter site (avoid femoral vein)
Daily review of line necessity – remove when no longer medically indicated.
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Systemic Complication: Venous Air Embolism (VAE)
CauseAllowing the solution container to run dry and
then hanging a new bagLoose connections that allow air to enter
systemPoor technique in dressing and tubing
changes for central linesPresence of air in administration set
Factors that must be present:direct communication with source of airPressure gradient
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Systemic Complication: Venous Air Embolism (VAE)
Signs and symptomsPatient complains of palpitationsLightheadedness and weaknessPulmonary: dyspnea, cyanosis, tachypnea,
expiratory wheezes, coughCardiovascular findings: “mill wheel”
murmur; weak, thready pulse; tachycardia; substernal chest pain, hypotension
Neurologic findings: change in mental status, confusion, coma
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Systemic Complication: Venous Air Embolism (VAE) (continued)
PreventionPurge all air from administration setsUse 0.22 micron air-eliminating filterFollow protocol for dressing and tubing
changes for central linesAttach piggyback meds to the proximal
injection portUse Luer-Lok connectorsDo not bypass the “pump housing” of EIDsAfter removal of central lines initial dressing
should be occlusive
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Systemic Complication: Venous Air Embolism (VAE) (continued)
TreatmentCall for help and notify physician immediatelyOnce VAE is suspected, any central line
procedure in progress should be stopped; clamp line
Place in Trendelenburg position on left sideAdminister oxygenMaintain systemic arterial pressure with fluid
resuscitation and vasopressorsMonitor vital signs If circulatory collapse initiate CPR
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CVAD Dressing Change
Prevention of infection is dependent upon
1. effectively reducing the number of microorganisms on the skin
2. Limiting access of the microorganisms to the catheter site.
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Discontinuing a CVAD
Only for percutaneous
Position: Trendelenburg
Valsalva maneuver during removal
Apply pressure
Pressure dressing
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Drawing blood from a central line(Dominican procedure)
Turn off IV solutionsFlush w/10 mL NSWithdraw 5 mL “discard”Use syringe or vacutainer to withdraw desired amt. bloodFlush w/ 20 mL NSLabel specimens “line draw”
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