School of Nursing - CSU, Chico

Venous Access Devices

This module will help you understand the differences in venous access devices. It is very general information and to be truly accurate you must also review your agency's policy and procedure (P & P) manual before accessing each device. This module does not cover arterial lines, dialysis lines, or Swan-Ganz catheters. The student is to read this module and complete the IVD on "IV Therapy" then take the test before accessing any IV. (See class syllabus/supplement for test dates.) Note that as of July 1 1999, OSHA has mandated that all hospitals use a needleless system. The use of "sharps" will damage many of the tubing systems and negatively affect your grade.

There are numerous ways and reasons to access a patient's veins. Patients may need IV therapy for hydration, antibiotics, and other medications, chemotherapy, blood draws, blood products, etc. The type of access device will depend on the patient, diagnosis length of time needed, life style, physician preference, patient's ability and preference, what the device is being used for, and difficulties using or maintaining the device. For instance, a patient who can't see or has arthritis may have difficulty maintaining a Groshong. If the patient is only going to have a device for a few days, a central line or LAC would be too costly and complicated.

There are three commonly used venous access devices (with several variations of each) currently in use in our local hospitals and agencies. You are used to seeing the peripheral IV. This is a catheter inserted in a peripheral vein on the hand, wrist, or arm (rarely the foot in an adult). If it is an infant or small child the feet and head veins are frequently used. A peripheral IV is used for some medications, blood products, fluid and electrolyte replacement for short periods of time. The site is usually changed every 72 hours (see individual agency's policy and procedure manual). A Long Arm Catheter (LAC) or Peripherally inserted Central Catheter (PICC) is used for long term antibiotic use, chemotherapy, total parental nutrition (TPN), blood products and blood draws. Central Venous Access Devices (CVAD), or central lines are used for blood products, blood draws, TPN, rapid infusion of large amounts of fluids, medications and other things. LAC, Pic, CVAD and MMC (multi-med catheter) are left in for months to years. It is imperative that you know what type of catheter your patient has because the care and accessing of the catheter varies according to size, location, and where it ends in the patient.

Peripheral Intravenous Catheters

Any RN, paramedic, or LVN trained to start IVs can start a peripheral IV. In preparing to start an IV, the nurse must know the P & P for the specific agency. She/he must explain the procedure to the patient and ascertain if the patient has any allergies to latex, Betadine, plastic or alcohol. The patient's veins are assessed. The nurse looks for valves, straightness of the vein, size of the vein, age of the patient, and the confusion of the patient. Keep in mind that the size of the catheter must fit the size of the vein and the reason for the IV. Patients must have a 20 gauge or larger for blood and at least an 18 gauge if it is a labor patient. An 18 gauge will not work for a newborn. Patients requiring venous access for the administration of IV medications, who will not require rapid fluid/blood administrations, may benefit from the use of a smaller catheter. Smaller catheters (i.e. 22 gauge) allow for greater hemodilution of medications and reduce the risk of phlebitis.

You will be using an over-the-needle catheter or a butterfly (usually for an infant) to start an IV in any of our agencies. The newer needles have built-in safety devices to help prevent needle sticks. You will need to check the P & P to determine your agency's use of T-catheters, prn adaptors (locks), or extension tubing. You will also need to check the P & P to see how often the IV and tubing needs to be changed and how to tape and dress the site after insertion. It is important to use the correct tubing for each patient and fluid.

After successful insertion, you will need to tell the patient not to manipulate the flow rate and to notify his/her nurse if there is any pain or leaking of fluid. Additionally, you need to note in the nurses' notes the size, site, time and any problems or special conditions that exist.

Sometimes the IV is connected to a "lock" instead of IV solution/tubing. Most of these locks or prn adaptors are flushed with saline, but some are flushed with heparin. You must know which type solution is to be used for your patient. Locks must be flushed every 8 hours or after each use. Use the acronym SASH to remember-saline, additive, saline, heparin. Saline must be used before and after the additive (medication) to keep the medication and heparin from reacting and to keep the catheter free of fibrin and blood clots.

Complications of peripheral IVs are infiltration, occlusion, phlebitis, catheter embolism and hematoma. Some medications cause severe necrosis and pain if they are infused into the tissues (extravasation) instead of the vein. It is very important that the site be assessed at least every shift and before each use and that a blood return is established before medications are instilled.

To permanently discontinue an IV you need a doctor's order. However, if a problem such as phlebitis, clogging, or infiltration has occurred you do not need a doctor's order to DC the IV or to restart it (nor for routine restarts). The doctor needs to be notified if a phlebitis occurs, if a medication extravasation occurs (especially certain drugs like dilantin or dopamine), or if the catheter is not intact when it is removed from the patient.

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Long Arm Catheters and Peripherally Inserted Central Catheters

A specially trained, certified RN inserts these catheters. The catheter is inserted under very sterile conditions. The major difference between these two catheters is where the tip of the catheter lies. The LAC tip lies mid-clavicle and a PICC tip lies in the vena cava. Although a LAC is not classically a "central line" it needs to be treated as such once inserted. These catheters come in a variety of sizes for children and adults. The only way to be sure if an IV is a LAC, PICC or peripheral is to read the most recent insertion notes. These notes are sometimes found in the progress notes.

In addition to being able to give most medications through these lines, they can remain in the patient indefinitely and blood can be drawn through them for laboratory tests (if greater than 3.9 FR). Therefore, it is important to know the size of the catheter so that you know what the line can be used for. You must also consult the P & P to know how your agency maintains the line. Most will require that the solution or medication be put through an electronic pump and that all lines be luer-locked. Blood pressures and tourniquets are not to be used above the insertion site. The circumference of the arm (at the documented position) must be measured every 8 hours, and the doctor notified of discrepancies. The external portion of the catheter must be measured every dressing change to be sure the catheter has not migrated. Use extra caution if giving mannitol, dilantin, Valium, or alkaline solutions through these catheters as these medications can easily clog the line, especially if the line is not flushed adequately before and after the drug.

If a LAC or PICC is locked off, it must be irrigated with 5cc of saline immediately after each use (20cc after blood products or draw has occurred) and then 3 cc of heparin (100 units/cc). Use 10cc or larger syringe to flush LAC/PICC lines. If the LAC is a Groshong (slit valve), it does not require heparin (although the physician may order it in certain situations.)

Discontinuing the catheter requires a doctor's order and must be done by an RN. The length of the catheter is measured and documented. Discrepancies from the original length must be reported to the doctor. Additionally, the doctor is notified if there is purulent drainage, redness at the insertion site or along the length of the catheter, tenderness/swelling at tip, increase in arm circumference size at marking and occlusion or accidental dislodgement. Under special circumstances these catheters can be repaired by specially trained nurses. A repair kit is kept at the patient's bedside and the doctor must be notified if a repair has occurred. The LAC can sometimes be un-occluded using special medications. You will not be giving these medications or repairing the lines. Don't even think about it.

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Central Venous Access Devices (Central Lines)

These catheters end in the vena cava, subclavian or femoral veins and must be inserted by a physician under very sterile conditions at the bedside or in surgery. Central lines may have several characteristics: tunneled or non-tunneled, open or slit valve, internal or external. Central catheters that have an open port (i.e. MMC, Hickman, accessed ports) need to have clamps and these clamps must be closed anytime the line(s)is/are not being used or if the system is open to air (during tubing changes). These catheters are locked off when not in use and must be flushed with heparin after the saline every 8 hours if locked and after each intermittent use. Many central catheters intended for long term use are "cuffed", meaning there is a cuff around the catheter just under the skin that helps prevent bacterial advancement.

Tunneled catheters have an entrance site distance from where the catheter enters the vascular system. These are "tunneled" through the skin and subcutaneous tissue to a great vein. This gives the body a chance protect the catheter from bacteria by the longer distance to the insertion site. These catheters are for long-term (years) use for patients who need chemotherapy, long-term antibiotic therapy, long-term TPN or frequent blood draws and/or blood products.

Non-tunneled catheters (percutaneously inserted catheters or multiple medications catheters (MMC) are for short term (5-7 days) use, monitoring the patient, multiple medications, blood products, blood draws, and TPN. MMC are inserted in x-ray, the cardiac catheterization laboratory, treatment rooms or at the bedside under sterile conditions.

The end of the central line may be open (which requires heparin and clamps) or slit valve (Groshong) which does not require clamps or heparin. The valve automatically opens outward during irrigation and fluid administrations and inward during blood withdrawal/aspiration. The valve stays shut if not in use. Groshongs are used for certain medication catheters (Groshong OTG) or LAC/PICC.

Central catheters can be internal or external. External catheters have the access ports outside the body and usually need more attention than internal catheters (i.e. more frequent flushing and dressing changes). Internal devices are completely under the skin and require piercing the skin each time the device is accessed. They may require special needles to access them and less frequent flushing. It is important to know the specific needle required to access an implanted port. A port may become damaged if accessed using the wrong equipment.

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Specific Central Catheters

External

Hickman (adult)/Broviac (child) catheters may be single or multi-lumen about 53" long. Broviac catheters are used for pediatric patients and sized accordingly. These catheters need heparin to maintain patency if not in use and must be clamped when not in use to prevent air embolism and hemorrhaging. Care must be taken when clamping the catheter so that is it not torn or cut.

Internal-Implanted Venous Access Devices

There are 2 types of these central catheters that have their entire system under the skin. The first have a reservoir with a self-sealing silicon septum and are called "Port-A-Cath" or Medi-Port". Implanted ports with a reservoir must be accessed with a special non-coring needle (Hubor) to prevent damage to the system. The second has no reservoir and is called a "Cath-Link". Cath-link uses a 20 gauge, 2" angiocatheter. You will get an immediate blood return that tells you the needle is correctly inserted. Cath-Link catheters may be used with Hickman-type catheters in the chest or arm (PICC).

The Port-A-Cath or Medi-Port are either metal or plastic, single or dual lumen and may be attached to a Hickman or Groshong. The site is identified and then cleaned with alcohol, then betadine, then allowed to air dry. The needle is inserted and verified by aspiration of blood, then dressed according to the P & P. It may then be connected to a lock or tubing.

Both of these types of implanted ports are central catheters and as such need to be accessed using sterile technique (masks and sterile gloves and set-up). The needle usually needs to be changed every 7 days, but again the P & P needs to be consulted. The ports need to be irrigated with 5cc of normal saline before and after medications. The catheters need to be irrigated with 20cc of saline after blood products or blood draw and monthly followed by 5cc of heparin when not in use or locked off.

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Special Considerations for Central Lines

Only RNs (and BSN students under the direct supervision of their instructor or preceptor) manage central lines. All infusions must be luer-locked in place and on an electronic pump. Only 10cc and larger syringes may be used to irrigate/flush the catheters/lines. The catheters must be sterilely maintained at all times and sterile gloves and a mask must be worn when the system is opened (i.e. when changing the lock or converting to tubing from lock and visa versa).

If you are drawing blood from any of these lines, you must clear the saline and/or heparin from the line prior to the blood draw. This involves withdrawing 5cc from the line. When irrigating a central line (PICC, LAC, MMC, implanted ports, etc) that is to be locked off, always flush with saline before the heparin. The amount of heparin varies from catheter to catheter, but always use 100 units/cc heparin. Some dialysis catheters have 5000-7500 units of heparin in them. DO NOT PUSH THIS INTO THE PATIENT AS IT WILL SIGNIFICANTLY ANTI-COAGULATE THE PATIENT.

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Complications of Central Catheters

Pneumothorax/hemothorax/hydrothorax can occur during insertion. The patient will complain of sudden onset of chest pain and dyspnea. The patient may be cyanotic and have decreased breath sounds. All patients need a chest x-ray after the catheter is inserted to make sure the catheter is properly placed before any fluids are given through the line.

An air embolism is another potential complication. The patient will experience respiratory distress, unequal breath sounds, weak pulse, decreased blood pressure and decreased LOC. All central lines must be clamped when open to air (changing tubing or PRN adaptors) and when not in use to decrease the risk of air embolism.

The vein into which the catheter is inserted may develop a thrombosis. There may be edema at the puncture site, erythema, ipsilateral swelling of the arm, neck and face, pain along the vein, fever, malaise and tachycardia.

Local infection (redness, warmth, tenderness at the catheter insertion site, purulent exudate, local rash) and systemic infection (fever, chills, leukocytosis, nausea/vomiting, malaise, increased urine glucose) may occur. The catheter must be
removed, and the tip cultured.

If the catheter (central) perforates the heart, cardiac tamponade can occur. Look for pulsus paradoxus, jugular vein distention, narrowed pulse pressure, muffled heart sounds, diaphoresis, and dyspnea. The patient needs immediate physician attention.

If fluids cannot be infused and the catheter is not clamped, it may be occluded. Most catheters need to be checked for blood return before attempting to instill medications followed by a 20cc flush. This is not recommended for PICC and Cath-Link catheters as aspiration of blood is equivalent to doing a blood draw. This may increase the risk of blood-based occlusion. Aspiration of these catheters should always be followed by 20cc NS using the start-stop technique to insure continuous catheter patency. The catheter may be un-occluded using a special procedure, but students will not be doing this.

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Conclusion

Given the increasing number of venous access devices, and the knowledge needed to maintain them safely, it is imperative that you master the information in this module and review it frequently. You must know what type of device your patient has. It is also critical to review the P & P of your institution when working with a new type of device and be aware that equipment changes frequently which means a change in the care of these catheters.

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Addendum

You must check with each agency for their specific requirements. There are slight variations at each agency, and these policies change very frequently.

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