Central Venous Access Catheter
A central venous access catheter is a sterile catheter made of polyurethane or silicone rubber (Silastic). It may have one, two, three, or four infusion ports, which can be used for administering fluids, blood products, drugs, and total parenteral nutrition. With the addition of specialized equipment, some central venous access catheters can monitor central venous pressure, central venous oxygen saturation, arterial oxygen saturation, pulmonary artery pressure, cardiac output, and temperature.
Central Venous Access Catheter Pathways
The illustrations below show several common pathways for central venous access catheter insertion. Typically, a central venous access catheter is inserted in the subclavian vein or the internal jugular vein. The catheter typically terminates in the superior vena cava. The central venous access catheter is tunneled when long-term placement is required.
Insertion: Subclavian vein
Termination: Superior vena cava
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Insertion: Internal jugular vein
Termination: Superior vena cava
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Insertion: Through a subcutaneous tunnel to the subclavian vein (a Dacron cuff helps hold catheter in place)
Termination: Superior vena cava
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Catheters impregnated with antiseptics, such as chlorhexidine and silver sulfadiazine, and antimicrobials, such as rifampin and minocycline, are recommended for a patient whose catheter is expected to remain in place for more than 5 days.1 Power injectable catheters are also available to enable power injection of contrast media in patients who require computed tomography and other testing.
The doctor inserts the central venous access catheter through a large vein, such as the subclavian vein or the jugular vein, and places the tip of the catheter in the superior vena cava. (See Central venous access catheter pathways.)
The duration of use varies depending on the type of device used. For example, standard subclavian, femoral, or internal jugular catheters are intended for short-term use (days). Other devices such as peripherally inserted central catheters (PICCs) are designed for long-term use (weeks or months). Some central venous access catheters, such as the Hickman and Broviac devices and implanted ports, can remain in place for months or years.
Central venous therapy increases the risk of complications, such as pneumothorax, sepsis, thrombus formation, and vessel and adjacent organ perforation (all life-threatening conditions).
Blood Sampling
Because multiple blood samples can be drawn through a central venous access catheter without repeated venipuncture, it decreases the patient’s anxiety and preserves peripheral veins. However, the catheter should be used for drawing blood only when necessary. If you don’t adequately flush the catheter after blood withdrawal, a thrombotic catheter occlusion can occur. When a central venous catheter has more than one lumen, use the larger lumen, usually the distal lumen, for obtaining blood samples. Avoid using the lumen that’s used for drug infusion.
Flushing
Flushing a central venous access catheter is done routinely to assess catheter patency before each infusion, to prevent mixing incompatible medications and solutions after infusion, and to prevent catheter occlusion after blood sampling.2 If the system is for intermittent use, the flushing and locking procedure will vary according to your facility’s policy, the medication administration schedule, and the type of catheter.
You must regularly flush all lumens of a multilumen catheter. To maintain patency in catheters used intermittently, facilities may use a heparin flush solution available in prefilled syringes of 10 units/mL heparin to lock the catheter. You should use preservative-free normal saline solution instead of heparin to maintain patency in two-way valved devices, such as the Groshong type, because research suggests that heparin isn’t always needed to maintain patency.
The recommended frequency for flushing central venous access catheters varies. When no therapy is being infused, follow these guidelines:
Flush nontunneled, nonvalved catheters at least every 24 hours. Based on facility policy, you may also heparin lock the catheter with 5 mL of 10 units/mL heparin.3
Flush nontunneled, valved catheters at least weekly. Based on facility policy, you may also heparin lock the catheter with 5 mL of 10 units/mL heparin.3
Flush tunneled, nonvalved catheters at least one to two times per week. Based on facility policy, you may also heparin lock the catheter with 5 mL of 10 units/mL heparin.3
Flush tunneled, valved catheters at least weekly. Based on facility policy, you may also heparin lock the catheter with 5 mL of 10 units/mL heparin.3
The flushing volume should be at least twice the internal volume of the central venous access catheter and injection cap. The size of syringe used for flushing varies according to the catheter’s manufacturer instructions, although most manufacturers require a minimum of a 10-mL syringe.2
Dressing and Injection Cap Changes
Despite the various designs and applications of central venous access catheters, certain aspects of dressing changes apply to all devices. Sterility and integrity of the catheter must be maintained at all times. Failure to properly maintain a central venous access catheter is associated with patient suffering, prolonged care, and increased expense. Inadequate insertion site care can lead to infection, sepsis, and death.
Most facilities have policies and procedures that address specific dressing change standards for each type of central venous access catheter. Semipermeable transparent dressings are changed at least every 7 days, and gauze dressings are changed every 2 days. Either dressing should be changed if the dressing becomes damp, loosened, or visibly soiled.1,4,5
Central venous access catheters used for intermittent infusions have needle-free injection caps (short luer-lock devices similar to the heparin lock adapters used for peripheral IV infusion therapy). These caps must be luer-lock types to prevent inadvertent disconnection and air embolism.6,7 The amount of air in a cap varies, so it’s important to air purge the cap before connecting it to the catheter hub.
The frequency of cap changes varies according to the manufacturer’s recommendations, your facility’s policy, and how often the cap is used. Change the cap if it’s removed for any reason, if there’s blood or debris within the cap, and before drawing a blood culture sample.7 Change the cap with each administration set change.1,6
Removing A Central Venous Access Catheter
Removing a central venous access catheter is a sterile procedure that’s usually performed by a doctor or nurse, either at the end of therapy or at the onset of complications.8 (Check your facility’s policy and your state’s nurse practice act to determine whether removing a catheter is in your scope of practice.)
If the central venous access catheter was inserted in an emergency situation, you should remove it as soon as possible, but not longer than 48 hours after insertion.8 Assess catheter necessity daily during multidisciplinary rounds, and remove the catheter as soon as it’s no longer needed; this reduces the risk of central line–related bloodstream infection.5,8,9,10 Consider the patient’s condition and therapy, catheter position, and catheter function when deciding whether to remove the catheter. If you suspect or confirm a central line–related bloodstream infection, base the decision to remove or salvage the catheter on blood culture results, the patient’s condition, available vascular access sites, effectiveness of antimicrobial therapy, and the doctor’s direction.8
Equipment
For Insertion of A Central Venous Access Catheter
Skin preparation kit, if necessary ▪ gloves ▪ blanket ▪ sterile gloves and gowns ▪ caps ▪ linen-saver pad ▪ sterile towel ▪ large sterile drape ▪ masks ▪ antiseptic solution (chlorhexidine-based is preferred, although you may use tincture of iodine, povidone iodine, or alcohol) ▪ antiseptic pads (alcohol, tincture of iodine, or chlorhexidine-based) ▪ preservative-free normal saline flushes in 10-mL syringes (one for each port of catheter) ▪ ultrasound device with sterile probe cover ▪ sterile ultrasound gel ▪ IV solution with administration set as ordered or needed for monitoring equipment ▪ 3-mL syringe with 25G 1″ needle ▪ 1% or 2% injectable lidocaine ▪ suture material ▪ two 14G or 16G central venous access catheters (antimicrobial impregnated, if indicated) ▪ catheter securement device, sterile tape, or sterile surgical strips ▪ sterile scissors ▪ sterile marker ▪ sterile labels ▪ transparent semipermeable dressing.
The type of catheter selected depends on the type of therapy to be used. (See Guide to central venous access catheters, pages 136 and 137.)
For Blood Sampling from A Central Venous Access Catheter
Gloves ▪ protective eyewear or a face mask ▪ prefilled flush syringes of normal saline solution ▪ alcohol pads ▪ blood collection tubes ▪ label for discard blood tube or syringe ▪ laboratory request forms and labels ▪ laboratory biohazard transport bag ▪ Optional: prefilled heparin flush syringe.
For the Vacutainer Method
Vacutainer with needleless adapter needle.
For the Syringe Method
Appropriately sized syringes (usually 5 or 10 mL) ▪ blood transfer unit.
For Flushing A Central Venous Access Catheter
Prefilled 10-mL syringe with heparin or normal saline solution ▪ alcohol pads.
For Changing the Dressing on A Central Venous Access Catheter
Gloves ▪ antimicrobial skin cleaner swabs (chlorhexidine preferred) ▪ sterile semipermeable transparent dressing or sterile 4″ × 4″ gauze pad ▪ sterile drape ▪ skin preparation solution (as needed to facilitate dressing adherence) ▪ catheter securement device, sterile tape,
or adhesive strips ▪ disposable surgical mask ▪ sterile gloves ▪ waterproof trash bag ▪ label ▪ Optional: chlorhexidine-impregnated sponge dressing, adhesive remover.
or adhesive strips ▪ disposable surgical mask ▪ sterile gloves ▪ waterproof trash bag ▪ label ▪ Optional: chlorhexidine-impregnated sponge dressing, adhesive remover.
EquipmentGuide to Central Venous Access Catheters
| Type | Description | Indications | Advantages and Disadvantages | Nursing Considerations |
|---|---|---|---|---|
| Groshong catheter |
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| Advantages
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| Short-term single-lumen catheter |
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| Advantages
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| Short-term multilumen catheter |
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| Advantages
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| Hickman catheter |
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| Advantages
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| Broviac catheter |
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| Advantages
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| Hickman/Broviac catheter |
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| Advantages
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Commercially prepared central venous access catheter dressing change kits that include most of the equipment needed are available.
For Changing an Injection Cap on A Central Venous Access Catheter
Gloves ▪ antiseptic pads (alcohol, tincture of iodine, chlorhexidine-based) ▪ sterile injection cap ▪ Optional: padded clamp.
For Removing A Central Venous Access Catheter
Gloves ▪ sterile gloves ▪ protective eyewear ▪ mask ▪ sterile suture removal set ▪ alcohol pads ▪ sterile 2″ × 2″ gauze pads ▪ forceps ▪ tape ▪ sterile, transparent semipermeable dressing ▪ antimicrobial ointment ▪ petroleum-based ointment ▪ Optional: agar plate or specimen container, if necessary for culture.
Preparation of Equipment
Gather all necessary equipment. Before insertion of a central venous access catheter, confirm catheter type and size with the doctor; usually, a 14G or 16G catheter is selected. Set up equipment for insertion, dressing change, and line removal, using strict sterile technique.12 Check all expiration dates, and inspect packages for any tears.
Implementation
For all procedures, confirm the patient’s identity using at least two patient identifiers according to your facility’s policy.13
Explain the procedure to the patient and answer any questions to decrease anxiety.
Assisting with Inserting A Central Venous Access Catheter
Ensure that the patient has signed a consent form, if necessary,14 and check his history for hypersensitivity to latex or the local anesthetic.
Perform a preprocedure check and a time-out verification process with the doctor according to your facility’s policy.15,16
Place the patient in Trendelenburg’s position to dilate the veins and reduce the risk of air embolism.
Elevate the bed to a comfortable working level to avoid back strain.
For subclavian insertion, place a rolled blanket lengthwise between the shoulders to increase venous distention. For jugular insertion, place a rolled blanket under the opposite shoulder to extend the neck, making anatomic landmarks more visible. Place a linen-saver pad under the patient to prevent soiling the bed.
Turn the patient’s head away from the site to prevent possible contamination from airborne pathogens and to make the site more accessible. Or, if dictated by facility policy, place a mask on the patient unless doing so increases his anxiety or is contraindicated because of his respiratory status.
Prepare the insertion site. Make sure the skin is free of hair because hair can harbor microorganisms. Clip the hair close to the skin rather than shaving because shaving may cause skin irritation and create multiple small open wounds, increasing the risk of infection. Clean the area with soap and water if the intended site is visibly soiled.11
Establish a sterile field on a table, using a sterile towel or the wrapping from the instrument tray. Prepare normal saline flushes using sterile technique and drop them onto the sterile field; if using prefilled flushes, drop them onto the sterile field using sterile technique.
Label all medications, medication containers, and other solutions on and off the sterile field.20
Put on a cap, a mask, and sterile gloves and gown to comply with maximum barrier precautions.
Prepare the insertion site with a chlorhexidine sponge1,11 using a vigorous side-to-side motion for 30 seconds; allow the area to air-dry.21
The doctor puts on a cap, a mask, and sterile gloves and gown. Assist with placing a large full-body sterile drape over the patient to create a sterile field and comply with maximum barrier precautions. Open the packaging of the 3-mL syringe and 25G needle and give it to the doctor using sterile technique.
Disinfect the top of the lidocaine vial with an alcohol pad and invert it. The doctor then fills the 3-mL syringe and injects the anesthetic into the site (as shown below).
Using sterile technique, give the doctor the ultrasound device with the sterile probe cover. Apply sterile ultrasound gel. The doctor locates the vessel using the device.
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