Joy Blacka (RN, BNg, MCP) Clinical Consultant Vascular Access

Transcription

1 Insertion & Management of CVCs & PICCs Joy Blacka (RN, BNg, MCP) Clinical Consultant Vascular Access

2 Workshop Outline Vascular Access Device Selection CVC & PICC Insertion Ultrasound Guidance in VA Safe utilisation of wires in VA PICC & CVC Exchange Assessment, detection & Management of complications with CVCs & PICCs

3 History of VADs William Harvey- Described the structure & function of the circulatory system. Used metal tubes as cannula Robert Boyle & Sir Chrostopher Wren- Crafted cannula from the quill of a birds feather William O Shaughanessy. Described black blood Severe salt & H2O depletion during chlorea epidemic 1831 Thomas Latta. Fluid replacement was necessary in Chlorea NB: IV Fluid Therapy not widely accepted as associated with high morbity & mortality. The fluids used were unsterile water, cows milk, albumin, various salt concentrations.

4 Health Outcomes The effect of treatment & care, by health professionals, on patients

5 Vascular Access Outcomes Successfully complete infusion therapy Reduced VAD related complications Reduced number of venepunctures per patient Patient Satisfaction Reduce exposure to blood borne pathogens Reduce supply & labor related costs

6 Clinical Information _iv_therap.asp

7 CDC 2010 Recommendations Select device based on intended purpose, duration of use, known infectious and noninfectious complications and experience of individual catheter operators. (pg. 64 Category 1B) Use a midline catheter or a PICC, instead of a short peripheral catheter, when the duration of IV therapy is likely to exceed six days. (pg. 64 Category 1B) Educate health-care workers regarding indication for ivcs, proper procedures for the insertion & maintenance of ivcs (pg. 63 Category 1A) Assess knowledge of & adherence to guidelines periodically for all persons who insert & manage intravascular catheters (pg. 63 Category 1A) Designate only trained personnel who demonstrate competence for the insertion and maintenance of peripheral & central intravascular catheters (pg: 63 Category 1A) Use ultrasound guidance to place CVCS to reduce number of cannulation attempts and mechanical complications (Pg 64 Category 1B) Use an antimicrobial or antiseptic impregnated CVC in adults whose catheters are expected to be > 5 days (Pg Category 1A)

8 Remember... The right device as early in the episode of care as possible

9 What is a Central line Where the tip of the catheter resides in the superior vena cava or the inferior vena cava

10 Vascular Access Peripheral Central

11

12

13 Vessel Diameter, Flow & CVCs Cephalic 40 ml/min Basilic 95 ml/min Axillary 333 ml/min Subclavian 800 ml/min Brachio-Cephalic800 ml/min SVC l/min

14

15 Subclavian / Axillary

16 CVC Insertion Points

17 Vein Assessment and Site Selection Basilic Vein Median Basilic Cephalic Median Cephalic Accessory Cephalic Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, Jan 2003, used with permission

18 Veins of the Upper Extremity and Thorax Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, Jan 2003 Gray, Henry. Anatomy of the Human Body. Philadelphia: Lea & Febiger, 1918; Bartleby.com, Jan 2003, used with permission

19 Vascular Access Devices Open Ended / Closed Ended Gauge / Sizes Silicone / Polyurethane Single Lumen / Multi lumen Basic Kits Full Kits Introducers

20

21

22

23 Trends with CVCs & PICCs Expanding Scope of Practice PICCs inserted with MI & Ultrasound at the bedside / procedure room Ø CT, Ø need for Power Injection via PICCs / CVCs Saline Only Maintenance Need to monitor CVP Ability to do a wire exchange

24

25 Vascular Access Ultrasound Internal Jugular Vein (IJ) 1. Hemodialysis 2. Port 3. Acute CVC 4. Tunneled CVC Subclavian Vein 1. Ports 2. Acute CVC 3. Tunneled CVC Basilic/ Brachial /Cephalic Veins 1. PICC 2. Midlines / Peripheral Cannulas

26

27 Insertion

28 Types of PICC Insertion Through the Peel-Apart Introducer /Sheath / Tear-Away Cannula Modified Seldinger

29 How you measure...

30 3 Ways To the SVC... palpate intercostal spaces regarding sternal angle (angle of Louis) between suprasternal notch and xiphoid process Oncology Nursing Society, Access Device Guidelines, Recommendations for Nursing Practice and Education, 1996 pg11 Lum P, (2004) A new formula -based measurement guide for optimal positioning of CVCs. JAVA, 9:2

31 Through the Peel-Away Cannula (Direct)

32 Advantages of MST Insertion Less Trauma during insertion Preferred method with US Enables insertion site above antecubital fossa Higher Success Rate Happier Patients

33 MST / Microintroducer 3. Dilator + Peel Apart Introducer 2. Guidewire 1.Small Needle or Cannula

34 MST Insertion

35 MST Insertion (cont.)

36 MST Insertion

37 Placement Wire (Stylet) and Guidewire Considerations Stylet Thin flexible wires placed within catheters to facilitate introduction Guidewire Thin flexible wires inserted into the vein to allow for sheath/dilator insertion Soft flexible tip Never cut a stylet/placement wire or guidewire

38

39 Kent, J. F. F. F. and T. F. Nedumpara (2007). "PERFORATION OF THE GALL BLADDER BY A PERIPHERALLY INSERTED CENTRAL CATHETER GUIDEWIRE: 'IF IT CAN HAPPEN IT WILL'. [Report]." ANZ Journal of Surgery March 77(3):

40 Variations on MST / Microintroducer

41

42

43

44 Raulerson Syringe

45 In all things, success depends upon previous preparation, and without such preparation, there is sure to be failure Confucius

46 Quiz Which vein/s can we use for inserting PICCs Which veins for IO of CVCs What IFC methods are utilised during insertion? What skin antiseptic is recommended for insertion & maintenance of VADs? What insertion methods can be utilised for insertion?

47 Post Procedure Xray Securement Documentation

48

49

50

51

52 POTENTIAL ASSOCIATED COMPLICATIONS Insertion of any vascular access device is an invasive procedure. The following complications can occur: Injury during insertion Phlebitis -Chemical -Mechanical -Infection related Haematoma Infiltration & Extravasation Embolism -Catheter -Thrombo -Air Infection

53

54

55

56

57 Infection Prevention Full Barrier Precautions with Insertion Use Aseptic Technique for all Manipulations of the Access Disinfect skin using a 2% chlorhexadine based solution Know your Products Wash thy hands

58 The facts: Australia Catheter Related Blood Stream Infection Occurs... At a rate of 23 per 1000 catheter days It has an 11% mortality rate = 392 deaths pa in Australia from a preventable adverse event Cost of CRBSI in Australia is estimated to be between $25.7 million AUD & $95.3 million pa. Bolz et al(2008) Management of CVCs in ICUs in Australia Healthcare Infection 13:48-55

59 Thrombosis

60 The Occluded Catheter! Hardy, G. a. and P. b. Ball (2005). "Clogbusting: time for a concerted approach to catheter occlusions?. [Article]." Current Opinion in Clinical Nutrition & Metabolic Care May 8(3): Hadaway, L. C. R. C. C. M. (2003). "Prevent occlusions with these flushing pointers. [Miscellaneous]." Nursing January 2003;33(1):28. Gorski, L. A. M. R. C. C. (2003). "Central Venous Access Device Occlusions: Part 1: Thrombotic Causes and Treatment. [Miscellaneous Article]." Home Healthcare Nurse February 21(2): Gorski, L. A. M. S. R. N. C. S. C. (2003). "Central Venous Access Device Occlusions: Part 2: NonthromboticCauses and Treatment. [Miscellaneous]." Home Healthcare Nurse March 21(3):

61 Types of Occlusions Mechanical Non- Thrombotic Thrombotic Occlusion Partial: one-way valve effect Complete Reasons for Occlusion: Mechanical: Kink in the catheter Positional the catheter rests up against the vessel wall preventing flow Catheter malposition secondary to poor dressing technique Ruptured catheter or Migration Non-Thrombotic: Intraluminal obstructions caused by: medication precipitates such as lipids, incompatible infusates/medications Poor flushing volumes in between incompatible medication administration Thrombotic: Intraluminal thrombus Extraluminal fibrin sleeve formation Mural thrombus (DVT) Complete occlusion of the vessel Gorski, L. A. M. R. C. C. (2003). "Central Venous Access Device Occlusions: Part 1: Thrombotic Causes and Treatment." Home Healthcare Nurse 21(2): Gorski, L. A. M. S. R. N. C. S. C. (2003). "Central Venous Access Device Occlusions: Part 2: Nonthrombotic Causes and Treatment." Home Healthcare Nurse 21(3):

62 Assessment & Detection of CVAD Occlusions Flushing (Resistance) Aspiration (Blood withdrawal / Patient position) The patient Check the external catheter Infusional Regimes X-Ray

63 Prevention is Easier than Cure

64 Flushing Hadaway, L. M. R. N. C. C. (2006). "Technology of Flushing Vascular Access Devices. [Article]." Journal of Infusion Nursing May/June 29(3):

65 Flush Techniques Pulsatile flushing to create turbulence & clean inside of catheter Positive Pressure - Clamp technique or positive pressure displacement devices - If using positive displacement devices DO NOT clamp until syringe is removed from injection bung

66 Technology: Needleless Injection Bungs

67 Getting the drug in

68 Macklin, D. (1999). "What's Physics Got to Do With It? A Review of the Physical Principles of Fluid Administration." Journal of Vascular Access Devices 4: 7-11.

69 Syringe Size for Flushing & Injection through VADs

70 GRIP-Lok The New Generation in Securement

71 Tips for Practice with Securement Attach securement device 2-3cms from insertion point Clean skin area with preferred antiseptic prior to application of securement. (Clip if hairy) Remember it needs to minimise risk of migration in or out.

72 Securement Device Features Soft and flexible fabric design improves patient comfort Low profile with no pins or hard plastic parts Provides excellent securement for both horizontal and vertical lifting accidental pulls Simple to apply, inspect and adjust Hypoallergenic, breathable and latex-free to reduce the risk of allergic reactions and skin irritation Easily secures to the hub "wings" or the alternate catheter clip

73 Dressing

74 Catheter Removal Removal by qualified individuals Removal procedure (sterile technique is used in many facilities) Patient supine, HOB elevated Maintain insertion site below level of heart Remove dressing Remove the catheter gently and slowly in 2-4 cm increments Have patient hold breath as catheter exits insertion site Cover the insertion site with a sterile dressing Measure and record the length of the catheter Document the procedure

75 Contact Information Joy Blacka E Learning PICC Insertion & Management Program nowledgelab/picc_lab.asp

76