Slide 1

Patient Care and Safety with Central Line Catheters and Arterial Lines

Debra Brady DNP RN CNS

Slide 2

What are Central Lines and Why Do Patients Need Them?

See the reading in Lewis on the Topical Course Outline before proceeding. This material will be included in MT 1 and your final for the course. This Module will focus on Patient Safety View the PP in the Notes format to see all of the information and clinical reasoning questions.

Most common sites Central Line IV Sites: R or L Internal Jugular, R or L Subclavian, R or L Femoral Peripherally Inserted Central Catheter (PICC) R or L Basilic or Cephalic vein in upper arm. (right arm peripheral due to angle) All Catheters except the PA Catherter end in Superior Vena Cava or in Right atrium Subsequent slides will provide details on types of catheters

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Check the Patients IV Site Know WHAT is infusing WHERE

Priority Steps: 1. Check the patients IV site and know what is infusing where. Are you working with a central line or a peripheral line? Some medications should only go in a central line {examples: Dopamine, Dobutamine, Norepinephrine (Levophed), Total Parenteral Nutrition (TPN)} 2. Verify that the fluid/medication hanging is ordered and labeled with the patient name, and date/time/initials of the RN who hung the bag. Bags hanging are good for 24 hours. Make sure the line is current. Lines are good for 72 to 96 hours depending on your facility policy. Look this up in the agency you work in. 3. Know what fluid or medication is infusing to a specific IV site and port, and document this in you charting. This PHOTO: This infiltration occurred because the patient had a vasoactive medication that causes vasoconstriction (Domamine or Levophed) infiltrate into the hand and vasoconstriction the blood vessels around the Peripheral IV. This causes tissue necrosis, and requires surgical repair with skin grafting. IV site assessment and management is the responsibility of the nurse. These medications should be infusing to a central line. Only in an emergency and for a temporary time frame would vasoactive medications be placed in a PIV. The nurses role is to advocate for central line placement by the physician or IV therapy team if these medications are given because they represent a patient safety risk.

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Always Label Lines

All IV lines need to be labeled with the medication in a minimum of 3 places: Bag, IV pump, Infusion port closest to patient. Units stock labels with printed drug names so that you can tag the line. Make sure that when hanging piggy back medications, you are accessing your mainline IV fluid or the appropriate medication line.

Slide 5

Central Venous Catheters (CVC)

Peripherally inserted central catheter (PICC) Implanted port Dialysis catheter

Temporary or permanent

Nontunneled or direct Central Venous Catheters

These are the categories of central venous catheters. There are different types.

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Central Catheters: PICC

Inserted via a peripheral vein in arm Catheter tip end: SVC Verify placement with chest X-ray 1-3 ports Low infection rates

Peripherally inserted central catheter (PICC) These are becoming the safest and most common central catheters used in the acute care and long term care settings. Low infection rates because they are impregnated with antibiotic coating, placed distal from the big blood vessel where infection can spread quickly. Preferred site is the R Basilic due to angle toward the Superior Vena Cava (SVC). Nursing Critical Reasoning question: If you were caring for a patient who was to have a PICC line placed by IV therapy in the next 24 hours, but the patient needed an immediate PIV started for IV pain med, what arm and area would you choose and what area would you avoid for the PIV start or any subsequent blood draws for labs?

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Peripherally Inserted Central Catheter

Indications Medications: vasoactive medications, TPN, antibiotics Monitoring Complications: What would you anticpate? Write out your answers the look further down the page: Answers: Infection (Increases with the amount of time this is in place. SS: redness/edema at site , pain at site, increasing WBC, fever). Prevent Infections. Meticulous dressing changes and cleaning of ports for 15-30 seconds before accessing decrease the risk of infections. These are very valuable lines and expensive to replace. Take good care of them. Deep Vein Thrombosis: the catheter sites is in a vien so it can block flow back to the heart leading to DVT in the upper extremityAlways assess size of arm with PICC with other arm, notify MD if there is swelling in the PICC arm. A venous ultrasound of the upper extremity is needed to see if there is a clot. Bleeding/hematoma at insertion site: rare, but can happen usually in first 24 hours. Catherter misplaced; rare because they are inserted with a vien finder ultrasound machine, but the catheters can move up the jugular vein instead of heading down into the SVC, so a Chest Xray in mandatory for confirmation. Clinical Reasoning Question: Why could you not just check for blood return to assess catheter placement?

Answer: if the catheter is in the jugular is will still enable drawing of blood

Slide 8
Power PICC can alsol Monitor Central Venous Pressures

The other thing the central lines can do is monitor central venous pressure in the SVC or right atrium by taking a pressure reading of the fluid against the catheter and converting this into a wave form on a monitor. (see Lewis 8th edition readings: 1687-1691) A specialized port on the PICC the Purple Power Port will allow this. The reading is called a Central Venous Pressure. If the pressure against the catherter is low=low volume in the venous system=low wave form on the monitor (low =<3, Normal 4-11, High 1216, super high needing diuresis = 17+) We use this information clinically to determine if a patient is dehydrated or over hydrated. For example in sepsis the CVP is usually low and our goal is to get the CVP up to 10-12. Contrast this with CHF or renal failure where you see CVP of 17 to 20 and know the patient needs diuretics or dialysis. The purple power picc port also allows for IV contrast injection for Interventional Radiology or for CT scans.
Slide 9

Central Catheters: Implanted Ports

Inserted in subclavian or jugular vein Accessed by special needle No visible port, diaphragm under skin Catheter tip rests in the superior vena cava Advantages

Low infection rates Can stay in several months

Implanted port A catheter inserted into the subclavian or jugular vein and attached to a fluid reservoir placed in a surgically created subcutaneous pocket on the upper chest. The catheter tip rests in the superior vena cava

Slide 10

central venous access needle diaphragm

Implanted Port:

reservoir

Indications: Long term drug therapy: usually for chemotherapy Lack of any vascular assess (pts with vascular disease) Complications: Infection (usually see systemic signs of fever and increased WBC)
Slide 11

Central Venous Catheters: Temporary Dialysis Catheters

Two ports Access to venous system only Blood from red port dialysis machine returned to patient via blue port FOR DIALYSIS ONLY (unless patient coding) Safety Issues: monitor for bleeding at site and infection.

A catheter inserted into subclavian, jugular, or femoral vein, two ports (red tip and blue tip but still accesses only the venous system;) Blood from red port dialysis machine-returned to patient via blue port; FOR DIALYSIS ONLY (unless patient coding, then is used as a main central line access)

Slide 12

Temporary Dialysis Catheters

NOTE: this catheter has a red and a blue port, but both ports have their own line inside the big white long catheter and it sits in a vein. Sometimes because there is a blue and red port nurses are confused that the blue is venous and the red is arterial. See highlights next slide. There is also a new dialysis catheter that has a third port between the red and blue, looks like the picture on the rightIt is a Tri-catheter; this one the nurse can use for infusing fluids or medications with permission from the Dialysis physician to use that portotherwise we do not access the dialysis ports, they are only used by the dialysis nurse.

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Non-Tunneled Multi-lumen Central Venous Catheter

Non-Tunneled = goes directly into big blood vessel, not tunneled under skin;

Sites: R or L jugular, subclavian, or femoral vein

Catheter tip:

Jugular or SC insertion ends in Right Atrium Femoral end is Inferior Vena Cava

MUST Verify with chest X-ray Two types used in clinical setting:

1. Central Venous Catheter (CVC) 2 or 3 lumens 2. Pulmonary Artery Catheter (4 or 5 lumens)

See the assigned reading in Lewis on these monitoring lines. Then go through the rest of the slides. They will make more sense. 1. Aka CVC or central line, double or triple lumen catheter. Nontunneled percutaneous central venous catheter A large-diameter catheter, usually with multiple lumens (see picture next slide) Advantages: quick access, can use for any medications or fluids. Is the most common of the emergently placed central lines. Monitor Central Venous Pressure to know fluid volume status of patient. In making an analogy to a car this catheterIt is kind of like the Ford Taurus of catheters not real fancy, but highly functional, can go just about anywhere and do anything you need and is reliable for a good price Pulmonary Artery Catheter: AKA: Swan Ganz Catheter (yes created by Dr. Swan and Dr. Ganz who are now retired on the royalties of these catheters and living on their own island somewhere in the Caribbean) This very specialized catheter allows us to measure the right heart volumes/pressures like the CVC; but also the pulmonary blood pressure and the LEFT heart pressures. It is used in patients with primary pulmonary hypertension or pulmonary disease or with heart disease/acute MI. In the car analogy this would be the Cadillac Seville.is really slick, not everyone needs one or gets one, but they sure are nice to have when you need fancy and lots of data.

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Multi Lumen Central Venous Catheter

Note the brown tip catheter, the outflow for this catheter tip is the most distal in the heart, this is the distal port and is where we would hook up a monitoring line for a CVP, but you can also run fluids through this port. SAFETY ISSUES Note the white and blue caps on the end of the catheter. This is important for patient safety to prevent air embolism if the catheter come disconnected from the IV line. Complications to monitor for: Slide 15

Central venous catheter

Allows monitoring of the volume of fluid returning to the right side of the heart, or allows fluids/meds to be immediately diluted in a large volume of blood.

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Pulmonary Artery Swan Ganz Catheter

Non-tunneled, PA catheter
Population Jugular, subclavian (rare), or femoral vein Tip rests in the pulmonary artery Multiple lumens:

CVP
PA IV ports

Pulmonary Artery Catheters (Swan Ganz) Nontunneled percutaneous central venous catheter A large-diameter catheter, with multiple lumens, inserted via the subclavian, jugular or femoral vein. The catheter tip rests in the PULMONARY ARTERY. Used to monitor pulmonary artery blood pressure and cardiac function, may give IV fluids through some of the lumens.
Slide 17

Pulmonary Artery Catheter

Slide 18

Anatomy

Slide 19

Pulmonary Artery Port (Yellow= WARNING)

Distal Port Tip rests in pulmonary artery Used for measuring pulmonary artery pressures and cardiac pressures only! No meds or fluids! Pressure bag

This is a major PATIENT SAFETY issue. A monitoring line will be set up to this port. It will have a pressurized bag with NS in it that will create forward pressure so that blood does not back up in the line causing it to clot. The pressure line is transduced into a wave form and reading you see on the monitor. Dr. Kelly will give you lots of details on this.

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Central Catheters:

Complications

Pneumo/Hemothorax

Injury to pleura, vein, artery or thoracic duct during catheter insertion S/S = SOB, decreased O2 sat, absent BS over upper lobe

Catheter tip mal-positioned

S/S: arm/shoulder pain, chest pain, cardiac dysrhythmias

Central catheters inserted into the Right or Left SubClavian are right over the lungs. Inserting to deep can result in puncturing a lung Jugular insertion can result in hematoma or bleeding at site, monitor for neck swelling. Femoral line complications: major factors are bleeding/hematoma at site, increased risk of infection because the groin is considered a dirty area with more bacteria; also pt can not sit up more then 30 degrees because the catheter can bend and break in the vessel. ALL central catheters can have the complication of mal-positioning/bleeding. PATIENT SAFETY; Place on O2 to keep sat > 95% STAT chest Xray

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Central Catheters:

Complications

Air embolism

Occurs when intrathoracic pressure becomes less than atmospheric pressure when the catheter is open to air and air enters the line. S/S: sudden respiratory distress, tachypnea, cyanosis, chest pain

If the catheter tip is left open to air this can cause an air embolism. PATIENT SAFETY Left side position in slight reverse trendelenberg is used if there is a suspected air emolism because it will put keep the air form the pulmonary outlflow track and will push it up to the apex of the heart on the right side where it can be absorbed or aspirated. Treat with 100% fio2, Echocardiogram can confirm presence of air.

Slide 22

Central Catheters:

Complications

Catheter embolism

Occurs when the catheter is pulled back and sheared off through inserting needle or from catheter rupture. S/S: chest pain, cardiac dysrhythmias

PATIENT SAFETY Left side position in slight reverse trendelenberg is used if there is a suspected tip emolism because it may keep it form flowing into the pulmonary outlflow track. The tip could be retrieved in Cath Lab or Interventional Radiology. Treat with 100% fio2, Echocardiogram can confirm presence of tip

Slide 23

Central Catheters: Nursing Considerations

Maintenance

Minimize entries into the system Strict aseptic technique

Needle-less access

Luer-lock

30/30 rule

Aspeptic techique means that you do everything you can to keep this catherter from becoming infected. Evidence based practice indicates: provide data and study:
Slide 24

Clean your handswear; wear gloves

Slide 25

Central Catheters:

Nursing Considerations

Site care

Wash your hands Assess dressing Assess catheter site Change dressing per protocol

Differs between type of access Usually a transparent dressing

Always remember to: wash your hands Assess the dressing for dried blood and secretions (the dressing should have: dated, time and initials) Assess the catheter insertion site for bleeding and secretions and note the length of the external portion of the catheter make sure the sutures are intact Change dressing according to hospital protocol (See Dressing change Proceedure),

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Central Catheters: Nursing Considerations

Slide clamps are used to prevent air embolism or blood backflow Never use a hemostat or sharp-edged clamp If clamping is not possible, have the patient perform a Valsalva maneuver when catheter is open to air.

Clamps are used when accessing VADs to prevent air embolism or blood back flow. Never use a hemostat or sharp-edged clamp that could damage or cut the catheter. If clamping is not possible, have the patient perform a Valsalva maneuver when catheter is open to air.

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Central Catheters: Nursing Considerations

Flushing

Never use excessive force; use a pulsing motion. Avoid using syringes <3ml in size to decrease pressure on catheter 10mL syringes are recommended Always flush post medications or blood draws

Never use excessive force when flushing VADs. Avoid using syringes less than 3 ml in size to decrease the pressure on the catheter. Syringe size directly affects the amount of pressure created by the force of the plunger: the smaller the syringe, the greater the pressure.

Slide 28

CVC NCLEX Question

The RN is caring for a patient who just underwent placement of a triple lumen CVC to the right upper chest. In planning the patients care the RN would anticipate the need to:
(SELECT ALL THAT APPLY)

A. Complete a STAT Chest X-Ray. B. Assess lung sounds and O2 sat frequently. C. Keep the patient on the left side for 2 hours post insertion.
D. Use needless screw caps on all lines.

See below for answer: Answer: A, B, D Left side position in slight reverse trendelenberg is used if there is a suspected air emolism because it will put keep the air form the pulmonary outlflow track and will push it up to the apex of the heart on the right side where it can be absorbed or aspirated. Treat with 100% fio2, Echocardiogram can confirm presence of air

Slide 29

Arterial Lines

Purpose

Monitoring Systemic Blood draws

NEVER inject into an arterial line. Attached to pressure bag with NS Inserted by physician, RN Monitory for Safety Concerns:

bleeding/hematoma circulation to distal extremity

Complications Disconnected/bleeding: always have monitor alarms set, and educate patient Hematoma at site: hold pressure firm to stop bleeding; notify MD Occlusion of artery: Decreased cap refill, cool extremity; notify MD STAT; discontinue Aline; monitor extremity for return of circulation; Occlusion of catheter; wave form flat; inaccurate monitoring will result, will need to be discontinued. Inaccurate monitoring: make sure the transducer is lined up with the left ventricle and it is zeroed to the phlebistatic axis every 4 hours and PRN with position change.
Slide 30

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Pressure Bag

Pressure bag is on the right; IV infusion bag is on the left. Never inject or hang a med into a pressure line.
Slide 32

Credits:

Photographers: Sam Parsons and Edie Schmidt

Academic Technology & Creative Srvcs., Academic Affairs, California State University, Sacramento

Scientific Illustrator/Designer: Edie Schmidt Lecture Outline: Debra Brady DNP RN CNS