Vascular Access via Central Catheter

New Hampshire
Division of Fire Standards
and Training and
Emergency Medical
Services

1
 Terminal Objective

 At the completion of this training the NH

Paramedic will be given the skills to access
existing central catheters with safe aseptic
technique for life threatening conditions with
clear indications for immediate use of
medications or fluid bolus.

2
 Enabling Objectives
 Explain the insertion sites for the various catheter
types.
 Describe the general principles, indications,
precautions, equipment, technique and
complications of vascular access via existing
central catheters
 Discuss infection, medical asepsis and the
differences between clean and sterile techniques.
 Describe the use of universal precautions and body
substance isolation (BSI) procedures when
accessing existing central catheters.

3
 Enabling Objectives

 Comply with universal precautions and body

substance isolation (BSI).
 Defend a management plan for vascular
access via an existing central catheter.
 Serve as a model for medical asepsis and
sterile technique.
 Serve as a model for disposing.
contaminated items and sharps.

4
 Enabling Objectives

 Identify various types of venous access

devices
 List at least three types of mechanical
occlusions.
 Use universal precautions and body
substance isolation (BSI) procedures during
medication administration.

5
 Enabling Objectives

 Demonstrate aseptic and sterile technique

during vascular access via an existing central
catheter.
 Demonstrate preparation and administration
of parenteral medications.
 Identify signs and symptoms of infiltration
 Identify improperly accessed devices

6
 Introduction

 CentralVenous Catheters (CVCs) were once

reserved for the acutely ill patient, with
advances in medical technology, all types of
CVCs are being utilized.

7
 Examples of CVC uses

– Parenteral fluids
– Caustic Medications eg. chemotherapy
– Long term pain management
– Blood and blood products
– Long-term Antibiotics
– Total parenteral nutrition (TPN)
– Patients requiring frequent or repeated blood
sampling (Catheters greater than 4 FR)
– Pressure monitoring
– Potassium
8
 Types of Vascular Access Devices

 Non-tunneling
 Tunneling
 Implanted

9
 Non-Tunneling

 Directvenipuncture through the skin into a

selected vein.
– Peripheral VADs
– Peripherally inserted central VADs
– Percutaneous catheters

10
 Non-Tunneling-Peripheral VADs

 Butterfly & angiocaths

– Short catheters generally placed in forearm, hand
or scalp veins
– Short term therapy and unable to handle caustic
chemicals (chemotherapy)

11
 Non-Tunneling - PICC

 Peripherally inserted central catheters (PICC)

 Midline
 Central venous catheter inserted at or above
the antecubital space and then advanced
until the distal tip of the catheter is positioned
at the superior vena cava or superior vena
cava and right atrial junction.

12
 Non-tunneling - PICC

 Useful for patient

receiving long term
medication therapy,
chemotherapy or TPN
 Used for frequent blood
sampling
 Distal end positioned
at the superior vena
cava or superior vena
cava and right atrium

13
 Non-Tunneling - PICC

 Peripherally inserted central catheters (PICC)

14
 Non-Tunneling - Midlines

 Used for shorter term

intravenous therapy
(up to 4 weeks)
 Used for frequent
blood sampling
 Distal end positioned
at the proximal end of
the upper extremity
15
 PICC versus Midline

16
 Non-Tunneling – PICC and Midline
examples at the antecubital & above

17
 Non-Tunneling – CVC

 Percutaneous catheters
 Also known as: Central Venous Catheters
(CVC)
– Subclavian or internal jugular
– Single, double or triple lumen

18
 Non-tunneling - CVC

 Tip advanced to superior

vena cava and right atrium
 As with PICC, appropriate
for patients requiring long
term chemotherapy or
TPN

19
 Non-tunneling CVC subclavanian site

20
 Tunneling

 Hickman®
 Broviac®
 Groshong®

21
 Tunneling

 Inserted into a central

vein via percutaneous
venipuncture or cut
down
 Catheter then tunneled
under the skin in the
subcutaneous tissue
and exited in a
convenient location
 Dacron cuff hold the
22 catheter in place
 Tunneling - Hickman®

23
 Tunneling - Broviac®

 Similar to the Hickman

catheter, but is of smaller
size.
 This catheter is mostly
used for pediatric
patients.

24
 Tunneling - Groshong®

 Similarto Hickman® and

Broviac® with closed
ended patented 3-way
valve.

25
 Implanted VADs - Ports
 Catheter attached to a
self-sealing silicone
septum surrounded by a
titanium, stainless steal
or plastic port
 Port sutured under the
skin
 Some brand names:
– Port-a-cath®
– Infus-a-port®
– Power Port ®

26
 Implanted VADs - Ports
 Catheter runs from
port to superior vena
cava at the right
atrium
 No part of the device
is exposed outside
the body
 Can deliver
chemotherapy, TPN,
antibiotics, blood
products and blood
sampling

27
 Implanted VADs - Ports

 Can only be accessed

with special needle
called a HUBER needle
 Contains a deflecting,
non-coring point

28
 Apheresis/Hemodialysis Catheter

 Indicatedfor use in attaining long and short

term vascular access for hemodialysis or
apheresis therapy

29
 Ready for a break?

30
 Insertion Complications

 Inadvertent Arterial Puncture

 Hematoma Formation
 Extravasation
 Infection
 Phlebitis
 Pneumothorax

31
 Systemic Complications

 Infection
 Deep Vein Thrombosis
 Pulmonary Embolism
 Superior Vena Cava Syndrome

32
 Mechanical Complication

 Catheter tip migration

 Broken or damaged catheter
 Catheter occlusion

33
34
 Risk of Infection

 Good aseptic technique must be utilized to

help prevent infection.
 The preferred method would be to utilize
sterile technique whenever possible.
 BSI

35
 Infection

 Infection- invasion of the body by pathogenic

microorganisms and the reaction of tissues
to their presence and to toxins generated by
the organisms

36
 Infection Process

 Involves three stages

– Invasion
– Localization/Containment
– Resolution
 Infection may revert back or become worse
at any stage of the process

37
 Infection Process - Invasion

 Invasion- introduction of pathogenic

microorganisms into the tissue
– May be result of violating aseptic or sterile
technique during wound preparation or medical
procedure.
– Poor skin/ wound preparation of a contaminated
wound
– Other routes

38
 Infection Process –
Localization/Containment

 The inflammatory response is the body's

initial defense directed toward localization
and containment of the infecting organism
 RBC’S, WBC’S, and Macrophages infiltrate
the tissue with possible abscess formation
 The body attempts to ward off the abscess
by building a membrane encapsulating the
tissue or cells
39
 Infection Process - Resolution

 Depends on immunological responses

capable of overcoming the infectious process
 Associated with drainage and removal of
foreign material, including debris of bacteria
and cells, lysis (disintegration) of
microorganisms, reabsorption of exudate,
and sloughing of necrotic tissue

40
 Factors that Contribute to Infection

 Infection results from the interaction between three

elements: organisms, tissues, and host defenses
– Organism - size and virulence have to do with
the microbes ability to cause disease
– Tissue - the condition of the tissue is significant;
necrotic, devitalized, avascular tissue or the
presence of blood or foreign bodies provide an
excellent media for pathogenic growth
– Host defense - the general health of the patient
influences resistance to microbial invasion
41
 Aseptic

 Aseptic technique is a set of specific

practices and procedures performed under
carefully controlled conditions with the goal of
minimizing contamination by pathogens

 1: preventing infection <aseptic techniques>

2: free or freed from pathogenic
microorganisms <an aseptic operating room>
42
 Sterile

 Free from living organisms and especially

microorganisms <a sterile syringe>

 Sterility will apply to SELECT surfaces of objects or

to substances that will be introduced into a patient’s
body. Some objects just don’t have the potential to
be made sterile. Hands can be made very clean but
not sterile. Gloves from the dispenser are not sterile,
nor are surgical masks. The message is: Only
specific, deliberately prepared surfaces or
43 substances are considered sterile.
 Aseptic Technique

 Barriersare established to control the spread

of microorganisms by:
– Protecting sterile areas
– Isolating surgical wounds
– Keeping free microbes to a minimum

44
 Aseptic Technique

 Skin
– Washing with soap (antimicrobial) before and
after patient contact
– NOTE: It is important to note that even under
emergency conditions, all steps necessary to
maintain asepsis should be taken.

– Donning gloves
 Mouth and nose
– A mask should be worn
45 – People with respiratory tract infections should
 Aseptic Technique - continued

 Fomites - nonliving material such as bed

linen that may transmit microorganisms
– Should be packaged and stored properly
– Clean and soiled supplies should be physically
separated
– Prompt decontamination of used equipment and
reusable supplies

46
 Sterile Technique

 NOTE: Aseptic techniques control microorganisms in

the environment, sterile techniques prevent transfer
of microorganisms into the body tissues.
 Need for sterile technique
– Freshly incised or traumatized tissue is easily
infected
– Intact skin is the body’s first line of defense
against infection
– Any break in the integrity of the skin is a potential
route of entry for infection
47
 Sterile Technique

48
 Opening a sterile kit or tray

49
 Opening a sterile kit or tray - continued

50
 Putting on Sterile Gloves

51
 Putting on Sterile Gloves - continued

52
53
54
 Sterile Technique

 The following sterile technique slides refer to

the hospital environment.
 It is expected that the paramedic will adhere
to the sterile technique outlined here as is
reasonability possible in the pre-hospital
environment.

55
 Sterile Technique - continued

 NOTE: If you have a question about the

sterility of an item, consider it unsterile!
When in doubt, throw it out!

56
 Sterile Technique - continued
 Assembles needed equipment and supplies
 Washes hands
 Creates a sterile field
 Adds sterile items to sterile field
 Adds liquids to sterile field
 Puts on sterile gloves
 Maintains sterile technique while performing activities
 Removes gloves
 Disposes of gloves, supplies, and equipment
 Washes hands

57
 Sterile Technique - continued

 Gowns are considered sterile only from the

waist to the shoulder-level in the front, and
the sleeves

 Sterile
people keep their hands in sight and
above waist level

 Hands are kept away from the face, elbows

58 are kept at the sides
 Sterile Technique - continued

 Tables are considered sterile at table level

only
– Only the top of a sterile draped table is
considered sterile (edges and sides are not)
– Anything falling or extending over the edge of the
table is considered unsterile
– Outer 1 inch edge of table top is considered
unsterile

59
 Sterile Technique - continued

 Only persons that are sterile touch sterile items

 Unsterile persons do not reach over a sterile field;
sterile persons avoid leaning over a sterile field.
 The sterile field is created as close as possible to the
time of use. The degree of contamination is
proportional to the time the sterile items are exposed
to the environment.

60
 Sterile Technique - continued

 Sterileareas are continuously kept in view.

Avoid turning your back to a sterile field, or
walking between two sterile fields.

 Integrity of the sterile package is destroyed if

it is perforated, punctured, or contaminated
with moisture

61
 Sterile Technique - continued

 Skin cannot be sterilized and is a potential

source of contamination. Scrubbing,
gowning, and gloving reduce the possibility of
contamination to a minimum.

 Where some areas cannot be scrubbed (i.e.,

mouth, nose, throat), masking reduces the
risk of contamination
 Airis contaminated by dust and droplets.
Environmental control measures must be
62 employed to control this source of
 Vascular Access via an Existing
Central Catheter

 Indications:
– In the presence of a life threatening condition,
with clear indications for immediate use of
medications or fluid bolus.
 Contraindications:
– Prophylactic IV access
– Suspected infection at skill site

63
 Determine the catheter type

 PICC
 Midline
 Broviac
 Hickman
 Groshong
 Mediport

64
 Procedure for Peripherally inserted or
Tunneled Catheters

 PICC
– Some brand names: Cook, Neo-PICC, BD, Arrow,
Bard
 Broviac
 Hickman
 Groshong

65
 Parts of the catheter

66
 Prepare your equipment

 10 ml syringe
(empty)
 10 ml syringe
(normal saline)
 Sterile gloves (if
available
 Alcohol preps
 250 – 1000 ml
normal saline and
administration set

67
 Syringe WARNING

 Do NOT use syringes less than 10 ml.

 Smaller syringes have greater pressure and
could rupture the line, vessel and/or viscus

68
 More than one lumen

 If the catheter has more than one lumen,

select the largest lumen

69 You will not always be able to tell the largest.

 Air Embolism WARNING

 There is a risk of air embolisms when a

central IV line is open to the air.
 Use a needle or utilize a needleless access
system for medication administrations
 Clamp the line whenever you remove the
injection port cap to attach or disconnect a
syringe or IV line.

70
 Clamping end of the cap

 Ensure the clamp

is properly
secured Clamp

71 End cap
 Prep end of lumen with alcohol swab

72
 Flushing
 Using aseptic technique attach 10 ml syringe of
normal saline
 Unclamp lumen
 Flush port with 3 - 5 ml of sterile normal saline to
determine patency.
 If catheter does not flush easily (note PICC line will
generally flush more slowly and with greater
resistance than a typical IV catheter) re-clamp the
selected lumen and try another lumen (if present)
 Re-clamp and discard syringe

73
 If You Are Unable to Flush

 Attach the empty 10 ml syringe and unclamp

the lumen
 Aspirate 5 ml of blood.
 Re-clamp and discard syringe with blood
 If clots are present, contact medical control
(MC) before proceeding.
 Re-attempt to flush
 If unable to flush, re-clamp and contact MC

74
 Accessing & Administration

 Attach IV administration set and observe for free flow

of IV fluid.
 PICC line generally will not free flow and will need a
pump
 Administer life saving medications or fluid bolus
 Watch for desired effects
 Reminder: You CANNOT give a rapid bolus
through a PICC line

75
 Fluid Administration

 Ifshock is not present, allow fluid to run at a

rate of 10ml/hour to prevent the central line
from clotting

76
 Maximum Flow Rates

 The maximum flow rates for a PICC line is

125 ml/hour for 3.0 Fr sized catheter or less
and 250 ml/hour for greater.
 Excessive flow rate can result in blowing out
the tip of the catheter
 You may need to check with manufacturer’s
recommendations

77
78
 Blood Pressure

 Avoid
taking a blood pressure on the same
arm as a PICC

79
 Implanted Catheter

 Use sterile technique

 Prepare equipment
 Identify site (usually located in the chest)
 Clean the access site with Choloprep
(Alcohol and Betadine if allergic)
 Allow the skin to air dry, if possible

80
 Attach 10 ml syringe to Huber needle

81
 Implanted Catheter

 Secure access point firmly between two fingers and

advance Huber needle into port at a 90 degree angle

82
 Implanted Catheter

 Aspirate 3 – 5 ml of blood with the syringe.

 If unable to aspirate blood, re-clamp the
catheter and do not attempt further use.
 If clots are present, contact medical control
before proceeding.

83
 Implanted Catheter

 Discard blood filled syringe

 Attached 10 ml syringe of normal saline and
flush with 3 – 5 ml.
 If catheter does not flush easily, re-clamp
and do not attempt further use.

84
 Implanted Catheter

 Attach IV administration and observe for free

flow of IV fluids
 Administer life-saving IV medications as
indicated
 If shock is not present, allow fluid to run at a
rate of 10 ml/hour to prevent the port from
clotting.

85
 Signs and Symptoms of Infiltration of
an Implanted Catheter

 Burning
 Numbness/tingling in the arm
 May see fluid accumulation
 If this occurs, discontinue and contact
Medical Control

86
 Questions?

87
 Acknowledgements
 Mello-Andrews, Rae, MS, RN, CEN, NREMT-P
 Doug Martin, NREMT-P
 Policies and Procedures for Infusion Nurses, 3rd Edition, INS, 2006
 NH Medical Control Board. 2007 NH Patient Care Protocols, Version
2, January 2007
 CDC, Morbidity and Mortality Weekly Report: Guidelines for the
Prevention of Intravascular Catheter-Related Infections. August 9,
2002/Vol. 51/No. RR-10
 University of North Caroline Hospitals. Nursing Procedures Manual:
Central Venous Access Device: Subcutaeous Implanted Port (Port-A-
Cath® Infus-A-Port®, Mediport®)-Accessing and General Information.
October 2005
 Cook Medical, Bloomington, IN
 Ohio State University Medical Center, Sterile Technique, June 2004

88