Chapter 24. Central Venous Access Devices
Access and Insertion
Melody Bullock-Corkhill, BSN, BS, MS, CRNI®∗
Assessment Factors Determining Catheter Selection, 480
CVAD Selection, 481
CVAD Insertion, 482
Special Considerations, 490
Insertion-Related Complications, 491
Summary, 493
ASSESSMENT FACTORS DETERMINING CATHETER SELECTION
Historically nurses have used peripheral IV access until no further access was possible due to hematomas, phlebitis, and, at times, even necrosis. Peripheral sites were considered less conducive to morbidity and mortality (Galloway, 2002). Evidence-based practice now indicates that an appropriate early assessment will direct the nurse in determination of the type of venous access device (VAD) based on patient needs, expected duration of therapy, medications, and diagnosis. Critically ill patients frequently need immediate venous access for the initiation of life support medications, solutions, antibiotics, and/or steroids. Nurses must be able to rapidly assess the availability of venous access and advocate for the patient. Triage becomes difficult during emergency situations when the patient is at highest risk and multiple attempts for access have been unsuccessful. The ability to administer intravenous medications directly affects the patient’s discomfort, morbidity, and mortality, which makes timely decisions even more urgent. The Centers for Disease Control and Prevention (CDC) recommends in the Guidelines for the Prevention of Intravascular Catheter-Related Infections that a midline or peripherally inserted central catheter (PICC) should be used if the duration of the therapy is to exceed 6 days (O’Grady et al, 2002).
The type of intravenous catheter a patient needs depends on several factors. The best time to evaluate venous access is before vascular integrity has been compromised. As soon as a nurse receives a patient for care, venous access availability should be assessed. Vascular damage can be avoided when the appropriate VAD is placed early in the patient’s plan of care.
Justification for a particular VAD selection depends on patient needs and the vasculature condition. Drugs known to be acidic, alkaline, hyperosmolar, irritating, or a vesicant require maximum hemodilution. This is accomplished by using venous access that allows the location of the catheter to be in a larger vein, terminating in the central circulatory system (INS, 2006a). When intravenous use will extend for longer periods of time, central venous access devices (CVADs) such as PICCs and tunneled catheters may be ordered. For a more permanent need, an implanted port may be the device of choice.
MEDICATIONS
Central venous access devices should be placed for patients who require medications that are known to cause damage to the inner lumen of the vein. Certain combinations of intravenous medications affect the veins in exponential proportions; damage done over time affects outcomes and may be irreversible (Forauer and Theoharis, 2003). The osmolality, pH, and classification as a vesicant or irritant of the prescribed medications should be considered before inserting a CVAD.
OSMOLALITY
Hyperosmotic describes solutions with a high osmolality—a high concentration of particles in solution—documented to cause trauma to the tunica intima if not diluted when infused (Fletcher and Bodenham, 2000). Many medications and solutions are classified as hyperosmotic including certain contrast media. An order for these medications or solutions should alert the nurse to the need for access that will allow a high rate of blood flow to further dilute the solution.
Solutions being infused should be close to the osmolality of blood serum, which is isotonic (250 to 350 mOsm/L), especially if the medications are infused in the smaller veins of the hands or arms since infusions in these veins may cause cell damage (Florence and Attwood, 2006). Fluids with an osmotic pressure of greater than 400 mOsm/L should also be infused slowly to reduce risk of venous damage. Using central access allows rapid dilution of solutions and medications with an osmolality greater than 500 mOsm/L, and decreases the potential for venous damage.
pH
pH is a significant factor when considering venous access. Device selection early in the course of administration of these drugs with extreme pH ranges will prevent unnecessary injury. Numerous litigious situations have occurred involving the intravenous administration of Phenergan, resulting in damage to veins, arteries, nerves, and tissues, even to the extent of appendage loss that results in significant changes in lifestyle (Shapiro, 2008). Phenergan for injection has a pH of 4.0 to 5.5. Vancomycin, with a pH of 4.0 to 6.0, is another drug that is known to cause vascular damage when mixed for infusion. Medications with a pH of less than 5 or more than 9 should be infused through a CVAD (INS, 2006a).
IRRITANTS/VESICANTS
The classification of a medication as an irritant or vesicant also affects the selection of the venous access device. An irritant is a medication that may cause itching, phlebitis, or reaction along the vessel or at the injection site, whereas a vesicant medication can potentially cause blistering, tissue sloughing, or necrosis when extravasation occurs. Extravasation is “the inadvertent leakage or escape of a vesicant drug or solution from a vein or unintentional injection into surrounding healthy tissues,” and may occur in as many as 0.1% to 6% of peripheral infusions, though these incidents are underreported (Wickham et al, 2006). Both cytotoxic and noncytotoxic drugs have the potential for being categorized as irritants and vesicants because of their chemical nature. This may have nothing to do with their pH or osmolality.
LENGTH OF THERAPY
Another factor influencing catheter choice is the prospective length of the prescribed therapy. Short peripheral VADs, midline catheters, and peripherally inserted central catheters are options depending on how long the patient will be needing treatment. While a peripheral site may be appropriate during the acute phase of treatment, a midline or PICC may be considered for a patient going home from the acute setting for extended therapy. Temporary central access is usually reserved for those patients who need immediate access where peripheral IV start attempts have been unsuccessful.
DIAGNOSIS
Because of the nature of certain diseases, many diagnoses will alert the nurse to potential complications and facilitate determining the venous access needs for that patient. Assessing the patient’s history and present diagnosis will help the nurse in selecting the appropriate VAD for the patient. Renal disease and diabetes contribute significantly to attaining and maintaining venous access. Common diseases that present infusion problems include cystic fibrosis, scleroderma, certain cancers, osteomyelitis, Crohn’s disease, hypotension, blood dyscrasias, gastrointestinal bleed, pulmonary hypertension, and long-term infections such as methicillin-resistant Staphylococcus aureus. These diagnoses can be an indicator for the insertion of a CVAD with a longer dwell time rather than a short-term peripheral device. Rapid assessment and placement of an appropriate VAD and reduction of peripheral venipuncture attempts have also been shown to assist with patient satisfaction (Elliott, 2006).
EXACERBATIONS
Patients with multiple medical conditions who receive numerous medications are prone to complications that may cause extended lengths of stay in acute care facilities and longer courses of intravenous medications, which may affect their lifestyle, their ability to work and continue daily activities, and ultimately their quality of life. A disease process that started out relatively simple can be complicated by secondary effects of the medications. For example, a patient with a respiratory tract illness requiring a relatively simple course of antibiotics and steroids may benefit from early intervention by having a CVAD inserted before the medications cause inner-luminal corrosion and inhibit further peripheral access.
CVAD SELECTION
Once the decision has been made for central rather than peripheral access the most appropriate device can be selected. Central venous access devices are catheters that terminate in the central vasculature, defined as the distal tip dwelling in the lower one third of the superior vena cava to the junction of the superior vena cava and the right atrium (INS, 2006a). There are a variety of soft, flexible CVADs appropriate for placement in patients with short- or long-term needs.
Patients who require multiple medications, such as those in the intensive care unit (ICU), will more likely need a catheter with multiple lumens. Other patients in an acute care facility may need a single- or dual-lumen catheter, depending on the types, amounts, compatibilities, and quantities of medications; the need for blood draws; and the need for the patient to continue using the catheter upon discharge. Placing a single-lumen catheter for patients who require treatment at home may simplify the regimen for home care.
Temporary or short-term devices, such as nontunneled catheters, are those that are removed relatively soon after placement. Most are used for a duration of 5 days to 4 weeks and then removed. In emergent situations where vascular access has been impossible, an intraosseous device may be required until venous access is more feasible. Refer to Chapter 20 for details on the various types of CVADs and their indications for use.
Long-term CVADs, including tunneled catheters such as Broviacs® and Hickman® catheters and implanted ports, can remain in place for years without problems. Implanted ports are indicated for patients with long-term intermittent infusion needs, while a PICC or tunneled catheter is typically used for continuous access. PICCs can remain in place as long as they are functioning properly. The general recommendation is to insert PICCs for therapy anticipated to be less than 1-year duration. CDC recommends central catheters should be replaced only when evidence of catheter-related bloodstream infection (CRBSI) exists (O’Grady et al, 2002). Studies of ICU patients with central venous catheters showed that there was no difference in infection rates between those who had catheters changed as needed and those who had them changed every 7 days (Stephens, 2005).
CVAD INSERTION
Central venous access devices fall under three categories: nontunneled catheters, tunneled catheters, and implanted ports. Tunneled catheters and implanted ports must be inserted and removed using local or general anesthetics. The nurse is responsible for assistance during insertion of the device and for care and maintenance once the catheter is in place. Documentation in the patient’s medical record should contain the insertion procedure, including the length of catheter inserted and the location of the catheter tip, skin disinfectant and local anesthetic used, flushing technique and solution used, catheter stabilization method (e.g., manufactured device, sterile tapes, sutures), patient response, and any specific action taken to resolve or prevent adverse reactions.
NONTUNNELED CENTRAL CATHETERS
Nontunneled central catheters are usually inserted at the bedside using a jugular, subclavian, or femoral approach, and are in place less than 14 days (Forauer and Theoharis, 2003). Sometimes these catheters are placed during an emergency or when the patient has no other access, unless the physician or emergency medical technician decides to place an intraosseous device. The Infusion Nursing Standards of Practice (INS, 2006a) recommends that catheters inserted during an emergency be replaced no later than 48 hours after placement. Care must be taken to prevent dislodgement, which can easily occur with these catheters.
TUNNELED CENTRAL CATHETERS
Tunneled venous access devices, such as Broviac®, Hickman®, and Hohn catheters, are placed for long-term therapy and are considered permanent since they are meant for use for a much longer time frame. After 10 to 14 days, adhesions form on the Dacron cuff that not only stabilize the catheter but also seal it, which prevents infection from the exit site to the vein. Typically patients with cancer or other chronic illnesses have a tunneled catheter placed for treatments that will be intermittent over a period of time, or for continuous infusions such as parenteral nutrition. After the insertion site is healed, the catheter is more difficult to dislodge and does not require a dressing, making it easier for the patient to maintain the site at home or to receive care in an outpatient setting.
IMPLANTED PORTS
Like tunneled catheters, implanted ports are used for long-term therapies, and are recognized as being beneficial to pediatric patients for their portability. They require no care when the patient does not need access, except for periodic flushing with 0.9% sodium chloride and instillation of heparinized solution. The patient can continue all normal activities when no treatment is being administered. Ports have relatively few mechanical complications compared to their
PROCEDURE FOR INSERTION OF A NONTUNNELED CENTRAL VENOUS ACCESS DEVICE
1. Explain procedure to the patient/family. Verify consent has been obtained.
2. Position patient in Trendelenburg or supine position for jugular or subclavian placement.
3. Identify patient using two identifiers. Ascertain patient’s allergies.
4. Perform hand hygiene using antiseptic soap for 60 seconds.
5. Prepare sterile field and supplies.
6. Clip hair on and around intended insertion site area.
7. Position drape underneath area to be cannulated.
8. Apply mask, gown, cap, and sterile gloves.
9. Prep site. If using alcohol and povidone-iodine swabsticks, begin with alcohol at the center of the intended site, cleanse using concentric circles, and allow to air-dry. If using chlorhexidine gluconate, use scrubbing motion back and forth for 20 seconds and allow to air-dry.
10. Drape patient using a full-body drape.
11. Change into second pair of sterile gloves.
12. Anesthetize the insertion site with 1% lidocaine.
13. Perform venipuncture into jugular, subclavian, or femoral vein.
14. Remove syringe from needle.
15. Insert spring guidewire through the needle.
16. Remove needle and place dilator.
17. Thread catheter over guidewire, aspirate, and remove guidewire. Flush with 0.9% sodium chloride and place caps on the hubs.
18. Secure catheter in place with a securement device; suture if necessary.
19. Apply sterile transparent membrane dressing over entire insertion site. Date and initial the dressing.
20. Obtain chest radiograph to verify tip placement and to rule out pneumothorax before initiating therapy.
21. Document procedure, patient tolerance during insertion, and monitoring in the patient’s medical record.
Obtaining access
Patients with implanted ports can carry on a normal lifestyle when the port is not accessed. An implanted port can be easily accessed for intravenous medications and for flushing to maintain catheter patency. Accessing a port is a sterile procedure requiring sterile gloves, a mask, and sterile supplies. A noncoring needle must be used to prevent openings in the septum from multiple accesses. Most noncoring needles are also 90-angled needles designed for patient comfort. An implanted port can be configured either as a single-lumen or as a dual-lumen device.
An implanted port consists of a small dome-shaped housing with a silicone septum underneath, which is a reservoir that empties into the catheter. A surgeon or interventional radiologist places the implanted port, creating a subcutaneous cavity, usually in the anterior chest wall; the port is attached to the muscle wall and then to a catheter leading into the central venous system. Ports have also been placed in the upper arm, abdomen, back, and side when anterior chest wall placement is not appropriate. In certain pediatric patients, ports have also been placed in the femoral vein with the tip terminating in the inferior vena cava.
To meet the needs of patients requiring repeat computerized axial tomography (CAT) scans with contrast, ports have been developed to withstand the high pressure of power injectors. These ports are recognizable by ridges on the surface or radiographic markings. When using power injectors, noncoring needles that have the tubing attached must also be FDA-approved for power injection to ensure that the tubing and connections will not rupture or separate.
Although the port is sutured into subcutaneous or muscle tissue, it can become unsecured and dislodged, making it difficult to access. If resistance is felt when attempting to access the port, the nurse should attempt again with a new needle. The needle requires only a minimal amount of pressure to access the port completely; and additional pressure may result in the needle bending back on itself, causing damage to the septum when being retracted. Once the needle “taps” the back of the port, a blood return should be visualized. If resistance is unresolved, the port may be partially or completely turned around in the subcutaneous cavity; this will require medical intervention.
When no blood return can be obtained, the nurse may flush the port and then attempt repositioning the patient; patients may be asked to turn their heads in the opposite direction, move their arms, or turn their body to the opposite side. If the port flushes well but no blood is aspirated the physician should be alerted so that an order can be written for an x-ray or dye study to determine the integrity of the catheter, especially if the port will be used to administer vesicants (Rosenthal, 2006).
PERIPHERALLY INSERTED CENTRAL CATHETERS
When assessment indicates the need for prolonged central placement, a PICC can be used for administration of multiple medications and for drawing blood samples. Comparative studies on open-ended PICCs and pulmonary arterial catheters showed correlating hemodynamic measurements, proving them beneficial for this as well (Santolucito, 2007). With almost half of intensive care patients requiring central access, PICC insertions rose from 11% in 1999 to approximately 29% in 2007. Size 6-French PICCs were recently developed, and have proven to be useful when practitioners use upper arm veins of adequate size, ultrasound guidance, and microintroducers for insertion (Nichols and Humphrey, 2008).
PROCEDURE FOR ACCESSING ADD DEACCESSING AN IMPLANTED PORT
1. Verify order for obtaining access. Identify patient using two identifiers, not including the room number.
2. Explain procedure and obtain consent from the patient. Ascertain whether the port is a power port. Apply topical anesthetic if needed.
3. Place patient in recumbent position. Assess the site for signs of inflammation and depth of the port. Clip hair at access site if needed. Determine gauge and length needed for noncoring, access needle. Gather supplies.
4. Wash patient’s port site with antiseptic soap and water if needed. Perform hand hygiene. Open supplies. Place noncoring needle, positive-pressure cap, and sterile 0.9% sodium chloride syringe on the field using sterile technique.
5. Place a mask on the patient if needed. Don sterile gloves. Place drapes around site.
6. Prepare noncoring needle by attaching a 10-mL syringe of 0.9% sodium chloride and priming the extension set and needle.
7. Cleanse site with antiseptic. If using alcohol and povidone-iodine swab sticks, start at the center of the skin directly above the port and clean in a concentric circular pattern using alcohol first followed by the iodine solution. If using chlorhexidine, cleanse using a back and forth scrubbing pattern. Allow to dry. Change to new clean sterile gloves.
8. Locate the septum and secure at three points with thumb and two fingers of nondominant hand. Holding the needle with the other hand perpendicular to the site, puncture the skin directly over the center of the septum with the needle, and access the port using one smooth motion until the needle touches the back of the septum.
9. Aspirate for blood return. Flush the port with 10 mL of 0.9% sodium chloride and follow with heparinized solution if the port will not be used for medications or will be deaccessed.
10. If the port will be used for an infusion, fold 2 × 2 gauze in half and place underneath the wings of the needle without obscuring the insertion site for visualization and assessment later; then place a sterile transparent membrane dressing over the site, making sure to cover the entire needle. The insertion site should remain unobscured. Secure the remaining tubing.
11. Document site assessment, procedure, size of needle, and blood return in the patient’s medical record.
12. When deaccessing, flush with 10 mL of 0.9% sodium chloride and instill 500 units of heparin in 5 mL of 0.9% sodium chloride or prescribed amount ordered. Remove dressing. Support the port housing with nondominant hand and remove needle without twisting, using a steady perpendicular motion.
13. Apply pressure for hemostasis; then cover with small dressing. Date and initial the dressing.
14. Document procedure, gauge/length of noncoring needle, blood return, instillation of heparin flush, and patient’s tolerance to the procedure.
Contrast media during computed topography (CT) studies were used for almost half of the exams during a 2006 study consisting of about 35 million cases (Santolucito, 2007). CT scans are ordered for diagnostic information for cancer staging studies, for abdominal pain diagnoses, for trauma, lung disease, and liver or pancreas disorders, to name just a few. Recently new peripherally inserted central catheters have been developed to allow injection of contrast media without rupturing the catheter, making PICCs invaluable to patients with multiple needs and venous access challenges. Many of these patients need CT scans quarterly as well as intravenous medications, and these catheters prevent multiple occasions for painful attempts at access.
Competency
The potential for success in a PICC program is high when certain variables are taken into consideration at the initiation of the program. For that reason, some organizations have requirements that must be met before a nurse is eligible to be taught how to place PICCs. First, they must be a registered nurse with a valid license. Then, many require 2 years experience and demonstrated competency in venipuncture and central line care followed by a program of training (Burns, 2005). Only nurses with documented advanced peripheral venous insertion skills should be considered for training of this advanced skill.
Extensive education and ongoing competency reviews should be the mainstay for nurses that insert PICCs. The learning curve for PICC insertion in adults using ultrasound is extensive, and possibly even more for pediatric placements. Mastery of ultrasound requires practice, usually 30 to 50 attempts (Hunter, 2007). Education should consist of a didactic course of study and testing, followed by hands-on instruction at the bedside. The didactic portion should include an anatomical review of the upper arm and central vasculature, measurement techniques, and placement. Following the PICC education program, a hands-on validation of the procedure with documentation is necessary. Annual competency checks and ongoing data collection regarding individual and team success rates validate the value of the PICC program to the patient and the organization.
Nurses with an understanding of the ultrasound for VAD placement will be at an advantage. Some nurses learn to place peripheral VADs with ultrasound before attempting to place a PICC. PICC education programs using ultrasound include visualization of the entire insertion procedure with incremental advancement of the catheter for proper placement. First the nurse learns to set up the sterile field with the appropriate supplies and how to establish maximum barrier precautions; the nurse then advances to the catheter placement. Most programs require correct placement of three to six PICCs before being “signed off” to practice independently (Burns, 2005). At that point the nurse inserting the PICCs should have someone to call for backup when problems are encountered. This is where a team approach with two nurses placing PICCs is helpful; however, most nurses can practice independently with relatively few problems.
There is debate among PICC teams regarding the length of time needed for a nurse to place a PICC. It is generally agreed that 2 hours is required, which includes the time needed for obtaining informed consent, assembling the supplies and equipment, performing the insertion, and documenting the procedure. A procedure lasting longer than 1.5 to 2 hours is usually not well tolerated by patients. Studies show that insertions requiring multiple attempts to cannulate the vein may increase the risk of infection or long-term complications (Chapman, Johnson, and Bodenham, 2006), since intraluminal damage may result in thrombosis, leading ultimately to infection. One study concluded that more than two failed punctures were associated with increased complication rates (Maecken and Grau, 2007).
Ongoing competency should be evaluated on a regular basis, and built into organizational policy and procedure. Quality and proficiency data maintained for each nurse will facilitate confidence in the nurse’s ability and reduce patient complications. PICC teams could benefit from ongoing data review of each nurse’s placement success rate. Some teams place the nurse into training remediation when his or her success rate falls below a certain percentage, and ask the nurse to step down from the team when the rate does not improve or falls a second time. The definition of “success” for an insertion usually refers to a catheter whose tip terminates in the distal superior vena cava. Other quality improvement data to collect that are valuable for improving outcomes would include types and rates of complications, especially infection.
Consent—ABCs
Informed consent has been a topic of importance for many years when it comes to medical procedures. Now, more than ever, it is important for patients to know the ABCs of PICC insertion so they may understand exactly what is happening before making a decision about their care. “A” refers to the alternatives, “B” to the benefits, and “C” to the possible complications. Many organizations have a separate consent for PICC insertion so that all information is readily available for the patient and nurse to discuss the procedure (Figure 24-1).
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| FIGURE 24-1 Sample consent form. (Courtesy of Moses Cone Medical Center.) |
Alternatives to PICC insertion include continuation of short peripheral devices, sometimes as frequently as every 12 hours when medications are irritating to the vein. The physician may place another type of central catheter that also has to be changed more often, making the PICC more appropriate. Whatever the reason, the patient should know why an alternative VAD is the best solution for the patient’s infusion needs.
Benefits of having a PICC placed include the ability to draw blood from the catheter and infuse multiple medications; PICCs also have been shown to have fewer complications (such as pneumothorax or pinch-off syndrome), can be used for cardiac monitoring, provide long-term access, and require relatively simple self-care. The cost is less than that for other types of access requiring insertion by a physician or interventional radiologist, and the insertion does not require general anesthesia.
Full disclosure of complications requires discussions about the following in conversation style and language the patient will understand:
• Bleeding
• Blood clot/thrombus
• Arterial puncture/damage
• Nerve damage
• Irregular heartbeat
• Infection
Supplies
A variety of PICCs are available on the market today, ranging in size from 1.9-French (1.9F) pediatric catheters to 7F triple-lumen catheters for adult patients. Most are made of silastic or polyurethane. PICCs can be open-ended or closed-ended catheters. The Groshong® catheter is closed-ended with a split tip valve to prevent air embolism, blood reflux, and clotting. Reverse-taper PICCs are graduated in size from the catheter to the hub to prevent bleeding at the site after insertion.
Catheter gauge, the measurement of the outer diameter of the catheter, depends on the catheter size. A 3F catheter is 20 gauge and a 4F catheter is 18 gauge, with gauge sizes varying from 18 to 20 gauge, or from 20 to 23 gauge for dual-lumen catheters. Flow rates will vary depending on the catheter gauge. Power-injectable PICCs have been developed to withstand injections of 5 mL of contrast medium per second.
In an effort to stem health care–associated infections, PICCs are being developed with antimicrobial coatings to prevent the formation of biofilm (Roe et al, 2008). The most common antimicrobials used to coat central catheters are chlorhexidine-silver sulfadiazine and minocycline/rifampin. There are chlorhexidene-impregnated foam disks that can be used at the insertion site to prevent infection as well.
Microintroducers are also available both in individual packets and in PICC insertion kits; refer to Chapter 20 for further details. Individual microintroducers are beneficial for cases when a second attempt at insertion is necessary. Any time the vein is to be cannulated more than once, a new needle and guidewire should be used. If only the needle is needed, echogenic needles can be purchased in individual packets as well. Guidewires come in various sizes and materials. To reduce the chance of injury to the vein wall or cardiac structures, flexible tip guidewires, usually 0.018 gauge, are recommended. The guidewire should never be advanced beyond the tip of the catheter.
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