63As discussed in the Chapter 4, reliable vascular access is a critical factor in successful home infusion therapy. Central vascular access devices (CVADs), commonly called “central lines,” are often placed for home infusion therapy because many home infusion therapies involve irritating drugs or fluids that would not be appropriate for peripheral infusion, or the anticipated duration of therapy is weeks to months. There are four main types of CVADs that are described in this chapter. Regardless of the type of CVAD, a central line is defined based on the internal location of the catheter tip. The tip should be located in the lower segment of the superior vena cava at or near the cavoatrial junction (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016).
This chapter provides a description of the four types of CVADs, care and maintenance guidelines, and potential complications.
After reading this chapter, the reader will be able to:
■ Differentiate between the four types of CVADs
■ Describe indications for CVADs
■ Summarize major aspects of CVAD care and maintenance
■ Identify potential complications of CVADs
64PATIENT SELECTION CONSIDERATIONS: CENTRAL VASCULAR ACCESS
The patient who requires a CVAD is most often referred to the home care agency with the CVAD already in place. In some situations, the home care nurse is involved in the decision-making process. If the patient’s infusion therapy is not appropriate for peripheral administration, as addressed in the previous chapter, a central line may be appropriate. Any type of infusion therapy may be administered via a central line. When selecting the type of central line, the process is collaborative among the interprofessional team, the patient, and the patient’s caregivers. For home infusion patients, consider the safety and the impact on activities of daily living as well as ability to care for the VAD. A qualitative study aimed at understanding the patient experience of peripherally inserted central catheters (PICCs) examined the experience of living with a VAD (Sharp et al., 2014). Themes identified included apprehension/adaptation/acceptance, impact of treatment, asking questions, and freedom (to receive treatment at home). Of note, although INS standards (Gorski, Hadaway, Hagle, McGoldrick, Meyer, & Orr, 2016) recommended the use of sites in the nondominant arm, arm choice had a marginal impact on activities of daily living for these study participants. The researchers asserted the importance of involving patients in clinical decision making by providing them individualized education and support needed as they adapt to living with the PICC.
The catheter with the fewest number of lumens to meet the patient’s needs is selected. When there are fewer lumens, there is less manipulation and access to the central circulation, which decreases the risk for catheter-related bloodstream infection. Furthermore, care is simplified for the patient.
TYPES OF CVADs
Peripherally Inserted Central Catheters
Description
■ The PICC is a central line that is inserted into the veins in the region above the antecubital fossa—the cephalic, basilic, or median cubital. PICCs are placed at the bedside by infusion team nurses who have completed education, training, and competency requirements as defined by the health care organization. PICCs 65are placed also by physicians or competent nurses in the radiology suite. Less commonly, PICCs are placed in the home by special nurse teams that utilize ultrasound and have radiology services available for catheter tip placement verification. PICCs, like all central lines, are placed under the conditions of maximal sterile barrier precautions with an independent observer ensuring that technique is not breached during catheter placement. It is important to recognize that PICCs are associated with an appreciable risk for catheter-associated vein thrombosis, especially in higher risk populations such as those patients with a cancer diagnosis. To reduce this risk, the catheter-to-vein ratio should be equal to or less than 45%, which allows more blood flow around the catheter in the vein (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016).
Advantages
■ Outside of the acute care setting, a low risk of infection
■ More reliable venous access than peripheral catheters
■ Lower cost of placement when compared to subcutaneously tunneled catheters/implanted vascular access ports
■ Single-, double-, and triple-lumen catheters available; most home infusion patients require only a single lumen
■ Can be used for routine blood draws
■ Can be removed in the home
Indications
■ Expected duration of intravenous (IV) therapy lasting for weeks, and generally up to a year. However, any CVAD is not removed based on dwell time because there is no known optimal dwell time (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016). In other words, if the PICC is functioning well without any signs of complications, it can continue to be used.
■ Patients requiring any moderate- to long-term infusion therapy such as antimicrobial drugs, chemotherapy, and parenteral nutrition.
Subcutaneously Tunneled Central Catheters
Description
■ The subcutaneously tunneled catheter is a surgically placed central line. The catheter is tunneled underneath the skin, usually on the chest wall. The catheter “entrance site” is located in the area of the clavicle where there is a small closed incision; this is the area where the catheter enters the venous circulation (Figure 5.1). The catheter is tunneled to an “exit site” lower on the chest where the catheter extrudes from the skin. A small synthetic “cuff” attached to the catheter is located within the subcutaneous tunnel and over time, the tissue attaches to the cuff and stabilizes the catheter in place (Figure 5.2). After the site is well healed, the catheter is difficult to dislodge and may even be managed without a dressing (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016). These catheters are often generically referred to as Hickman or Broviac catheters, although these are registered trademark names for catheters made by Bard Access Systems.
66
Figure 5.1 Subcutaneously tunneled central venous catheter placement.
Note: Note the catheter entrance site, where it enters the venous circulation, often via the internal jugular or subclavian vein, and the exit site, which is the focus of catheter site care.
Advantages
■ Long-term catheter with relatively low risk of infection and catheter-related complications
■ Repairable
■ Single-, double-, and triple-lumen catheters available
67
Figure 5.2 Subcutaneously tunneled catheter.
Note: Note the synthetic “cuff” that is attached to the catheter.
■ Can be used for routine blood draws
■ May remain in place for months to years
■ May not require dressing after tunnel tract is well healed
Indications
■ Expected duration of IV therapy months to years
■ Patients requiring long-term parenteral nutrition, chemotherapy, or other long-term infusions
Nontunneled Central Vascular Catheters
Description
■ Refers to the percutaneously placed catheter that may be placed via the subclavian or internal jugular route. These catheters are placed by a physician or competent infusion team nurse in the acute care setting. They are infrequently used in home care, but some patients may be discharged with a nontunneled catheter in place to complete shorter courses of home infusion therapy.
Advantages
■ Lower cost of insertion compared to subcutaneously tunneled catheters
■ Single-, double-, triple-, and quadruple-lumen catheters available
■ 68Can be used for routine blood draws
■ May be removed in the home setting; however, there is appreciable risk of air embolism during removal
Indications
■ Expected duration of IV therapy days to weeks
■ Any infusion therapy requiring central vascular access
Implanted Vascular Access Ports
Description
■ The implanted vascular access port is a surgically placed device. Patients may have ports placed in outpatient surgery by a surgeon or, alternatively, they may be placed by an interventional radiologist in the radiology department. Placed completely underneath the skin, the port consists of a catheter attached to a reservoir (port) and is accessed through the skin using a special noncoring (i.e., Huber) needle. The port may be located in the chest (Figure 5.3), but there are also peripheral ports where the port body is located in the antecubital area (the catheter is threaded through the peripheral veins to the superior vena cava, like a PICC).
Figure 5.3 Implanted venous access port placement in the chest.
Advantages
69■ Low risk of infection and catheter-related complications
■ Improved body image—no external evidence of port other than a small “bump”
■ Single- and double-lumen catheters available
■ Can be used for routine blood draws
■ Minimal maintenance required—no dressing unless being actively used for infusion; usually monthly catheter locking (heparin or saline) to maintain patency
■ May remain in place for months to years
Indications
■ Expected duration of IV therapy months to years
■ Patients with intermittent need for infusion therapy (e.g., chemotherapy and transfusions)
■ Patients on long-term cyclic parenteral nutrition who prefer to access the port for every infusion than live with an external device
COMPREHENSIVE CARE, ASSESSMENT, AND MONITORING
Regular Site Assessment
■ With every home visit, assess for intactness of the dressing, presence of any site redness, tenderness, swelling, drainage, and/or the presence of paresthesias, numbness, or tingling at the site; evidence of possible CVAD-associated venous thrombosis including edema/pain/engorged peripheral veins in the extremity, and/or difficulty with neck/extremity motion. The assessment includes visual assessment, palpation, and subjective information from the patient.
■ Measure external catheter length at each visit and compare to previous measurements to identify possible catheter dislodgement.
■ Assess midarm circumference prior to PICC placement or at first home visit to establish a baseline (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016, p. S29). Should there be a suspicion of catheter-related venous thrombosis (pain, edema, erythema, and change in extremity mobility), remeasure midarm circumference to compare to baseline. In a prospective study of patients with peripherally inserted central catheters (PICC), a 3-cm or greater increase in arm circumference was associated with upper arm venous thrombosis (Maneval & Clemence, 2014).
■ 70Assess and ensure catheter patency. Flush and aspirate for a blood return, defined as blood that has the color and consistency of whole blood (Gorski, Hadaway, Hagle, McGoldrick, Orr, & Doellman, 2016) prior to each infusion.
Fast Facts in a Nutshell
