Long-term central venous catheters, for example, PICCs, VIDs, and tunneled access devices (TADs) are placed to reduce the trauma of repeated venipuncture. This chapter focuses on TADs, which are surgically inserted and removed by a physician or validated Advanced Practice Registered Nurse (APRN) or Physician Assistant (PA) under sterile conditions and are used for direct administration of IV fluids, intermittent medications/therapies, blood products, parenteral nutritional, and venous blood sampling for laboratory analysis. They may be used in the home setting for continuous infusion of medications, chemotherapy, and parenteral nutrition and therefore contribute to the improvement of the child’s quality of life.
TADs may be accessed and site care or infusion given by a validated care provider or appropriately trained child or caregiver.
There are two types of TADs: the nonpower injectable and power injectable, which may be valved or openended TADs (Figure 56-1). Examples of brand names are Hickman or Broviac. Nonpower injectable TADs may be used to administer hand-injected contrast media. Power injectable TADs, rated with a psi of 300, may be utilized with the power injector to administer contrast media in the CT or MRI suite. TAD valved catheters have a valve either in the tip of the catheter or in the catheter connector to prevent backflow of blood. The underlying condition of the child, the indication for use, and the capability of the family or child to perform self-care of the long-term catheter necessary for home maintenance help determine which catheter is appropriate for a specific child. TADs are better suited to very small children, infants, and neonates.
Figure 56-1 The TAD is tunneled through the vein until the tip reaches the superior vena cava.
Use aseptic technique when caring for or using longterm venous access catheters to minimize the associated risk for infection.
Follow manufacturer’s instructions for the specific catheter.
Change the dressing weekly or PRN when it becomes loosened, damp, or soiled, or when inspection of the site is necessary.
Change the needleless neutral or positive pressure catheter cap weekly with dressing changes or PRN if residual blood remains after blood is drawn.
All add-on devices have a Luer-Lock design.
Intravenous fluids are administered via a controlled infusion device.
When not in use, place an open-ended catheter to heparin lock (saline lock in valved catheters); then cap and secure with tape to the chest under the child’s clothing. When the catheter is used as a heparin-lock device, flush the line after each use or at least once daily. The healthcare prescriber must order the frequency of flush and the amount of solution used.
Aseptic technique is used when caring for or using long-term venous access devices to minimize the associated risk for infection.
A 2% chlorhexidine-based preparation is the preferred solution for skin antisepsis. Tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used.
Follow manufacturer’s instructions for the specific venous access devices.
Nonsterile gloves
Soft jaw clamp (if catheter does not already have clamp preattached)
Sterile 10-mL syringe
Sterile needleless neutral or positive pressure connector
Sterile preservative-free 0.9% sodium chloride (10 mL) for injection
Antiseptic swabs (Table 57-1): 2% chlorhexidinebased preparation is preferred; tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Prescribed fluid for administration, and IV flow control infusion device (follow manufacturer’s directions for use)
Tape
Flush solution:
For open-ended catheters: heparinized saline, 10 units/mL (per healthcare prescriber’s order, preservative-free in neonates); and sterile preservativefree 0.9% sodium chloride (10 mL) for injection
For valved-type catheters: sterile preservative-free 0.9% sodium chloride (10 mL) for injection
Nonsterile gloves
Sterile gloves
Sterile towel
Antiseptic swabs: one 2% chlorhexidine-based preparation is preferred, three tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Dressing materials: sterile semipermeable transparent dressing and a chlorhexidine patch (optional)
Sterile needleless neutral or positive pressure catheter cap
Needleless disinfectant cap (optional)
Nonsterile gloves
Soft jaw clamp (if catheter does not have a preattached clamp)
Antiseptic swabs: one 2% chlorhexidine-based preparation is preferred, three tincture of iodine, an iodophor (e.g., povidone-iodine), or 70% alcohol can be used
Two sterile 10-mL syringes
Appropriate syringes, number and size determined by blood specimens needed
Sterile needleless access devices (per institutional policy)
Flush solution:
For open-ended catheters: heparinized saline, 10 units/mL (per healthcare prescriber order, preservative-free in neonates); and sterile preservative-free 0.9% sodium chloride (10 mL) for injection
For valved-type catheters: sterile preservative-free 0.9% sodium chloride (10 mL) for injection
Tape
Specimen tubes for ordered laboratory tests
Biohazard bag
Ice, if needed for blood specimen
Specimen labels and requisitions
Discuss with the child and family the purpose of TAD placement and the intended reason for use.
Assess the child’s and the family’s cognitive level, readiness, and ability to process information. Readiness to learn and process information may be impaired as a result of age, stress, or anxiety.
Explain the procedure, as appropriate, to both the child and the family.
Reinforce the need, and identify and discuss the risks and benefits of long-term IV catheter placement, as appropriate, to both the child and the family.
Assess the child’s baseline vital signs and observe for changes that may indicate a local or systemic infection. Infection may occur as a result of the presence of a foreign body in the subcutaneous tissue; accessing the catheter, which may introduce bacteria into the catheter; bacterial contamination at the exit site from loss of intact skin protection; and the necessity of long-term venous access and home maintenance procedures, which also may increase the risk for infection.
Assess the child’s age, general size, and overall skin condition. Observe for peripheral skin grafts or shunts, cellulitis, vascular surgeries, thrombosis, or peripheral vascular disease, which may limit the dwell time of the TAD. Assess the skin surrounding the catheter for pain, swelling, venous distention, or development of collateral circulation, because this may aid in detection of venous thrombosis.
Explain the symptoms that may indicate complications and the need for catheter removal and having a new catheter placed. This enables the child and family to recognize when the catheter is not functioning properly and when to notify the nurse. Complications associated with long-term venous access catheters include infection, phlebitis, thrombosis, catheter occlusions, and mechanical malfunctions.
PROCEDUREAccessing, Flushing, and Locking a Tunneled Access Device
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