Choices and Challenges with Central Venous Catheters. Joy Blacka (RN, BNg, MCP) Clinical Consultant

Transcription

1 Choices and Challenges with Central Venous Catheters Joy Blacka (RN, BNg, MCP) Clinical Consultant

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

3 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

4 Clinical Information -for-the-prevention-of-intravascular-catheter-relatedinfections.aspx PG_Guide_C4_iv_therap.asp erapy.pdf

5 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)

6 CDC 2010 Recommendations Choose the device to match the therapy (pg. 14 Category 1A) Patients requiring 6 or more days of IV therapy should be assessed for a PICC or Midline (pg. 16 Category 1B) Educate health-care workers regarding indication for ivcs, proper procedures for the insertion & maintenance of ivcs (pg. 13 Category 1A) Assess knowledge of & adherence to guidelines periodically for all persons who insert & manage intravascular catheters (pg. 13 Category 1A) Designate trained personnel for the insertion and maintenance of vascular catheters (Category 1A) Use an antimicrobial or antiseptic impregnated CVC in adults whose catheters are expected to be > 5 days (Category 1B)

7 Quality Improvement / Clinical Governance / Best Practice How do we improve processes? How do we facilitate change? How do we improve patient outcomes? Why do we need to improve practice with Vascular Access?

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14 This investigation has now been completed. The results of this investigation have shown that there are no inherent flaws in any of the PICC lines. However, as with all medical devices it is important that Instructions for Use are carefully followed. The TGA has identified opportunities for improvements that can be made to the current label warnings and Instructions for Use accompanying all of the devices. The TGA believes that such improvements will assist users of the devices and has requested the sponsors of the devices to undertake these changes. www,tga.gov.au

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16 Improvement Practices & Bundles A Bundle is a collection of processes needed to effectively and safely care for patients undergoing particular treatments with inherent risks. Several interventions are bundled together and, when combined, significantly improve patient care outcomes.

17 What is a bundle? - Small Should be - Straightforward - A set of three to five level 1 evidence based practices - Individual elements of the bundle must each be proven to be necessary for the best care but only together do they cause significant improvement - Synergy

18 NSW CLAB Project oreinfo/clab.html /curren

19 Early IV Vascular Access Assessment Reactive versus Proactive IV Therapy Reactive Patient is admitted with a wound infection and a short peripheral IV catheter is initiated for vancomycin Device selection is not considered Peripheral therapy is routine until patient s veins are exhausted Proactive Patient is admitted and assessed for type of IV device. The vascular access device is selected based on these parameters: Dx, Length of therapy, Type of Drug, vein status, and medical history. PICC line is placed

20 Outcomes Reactive Patient has multiple short peripheral sticks with risks of phlebitis, infiltration, and/or extravasation complications. Hospital has increased cost in labor and materials associated with multiple short peripheral sites and phlebotomy sticks Proactive Completes therapy with one vascular access device without complications. Hospital has utilised the most cost effective device for the patients therapy thereby controlling operational cost. Increased patient satisfaction

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23 Remember.. The right device as early in the episode of care as possible Ludeman, K. R. C. C. M. (2008). "Which vascular access device is right for your patient?" Nursing Made Incredibly Easy! July/August 6(4): 7-11.

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

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28 Some of us will do our jobs well and some will not, but we will be judged by only one thing - the end result ---Vince Lombardi

29 Morning Tea

30 What is a Central Venous Line / Catheter? The tip of the catheter resides in the distal 1/3 rd of the superior vena cava or the inferior vena cava.

31 Which Therapies Require Central Venous Access Multiple Infusions Fluid Monitoring Blood Letting Poor Peripheral Access Extended Length of therapy Hypertonic, Vesicant or ph Extremes

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33 Central Lines Peripherally Inserted Centrally Inserted Short Term / Long term

34 Percutaneously Centrally Inserted Central Catheters (Acute Lines) Tip residing in the distal 1/3rd of SVC Short Term Line (<30 days) Xray required Expert Clinician to insert

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37 Peripherally Inserted Central Catheters A catheter inserted into a peripheral vein with the tip residing in the distal superior vena cava

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40 Long Term Tunneled Centrally Inserted Central Catheters Broviac & Hickman Tip in Vena-Cava Surgical or Radiologically Placed Catheter X-ray required Long Term (> 6 weeks to > years)

41 Insertion Point Exit Site

42 PORTs

43 Implanted Ports

44 Accessing & Deaccessing a Port Huber Point Needle (non coring) Locate the Port Right Gauge & Length Needle Dwell Time Secure & Dress Keep Safe!!!!!!

45 Dialysis Catheters Non Cuffed (Acute) Dialysis Cuffed Dialysis (Chronic) Ash, S. R. (2007). "Fluid Mechanics and Clinical Success of Central Venous Catheters for Dialysis-Answers to Simple but Persisting Problems." Seminars in Dialysis May/June 20(3):

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

49 CVADs & Ambulatory Care

50 Elastomeric Devices

51 Quiz Name two short term CVCs Name three long term CVCs Where does the tip of a CVC sit What assessment criteria should you use when choosing a VAD for a patient

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53 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 Infiltration & Extravasation Embolism -Catheter -Thrombo -Air Infection

54 Infiltration / Extravasation

55 How do you clinically check the ongoing position of a VAD External length of catheter Aspiration of blood Flushing of Catheter

56 Infection

57 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. Casey, A. L., L. A. Mermel, et al. (2008). "The Lancet Infectious Diseases." 8 (12): Bolz et al(2008) Management of CVCs in ICUs in Australia Healthcare Infection 13:48-55

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60 INFECTION ENTRY ROUTES

61 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

62 Clinical Practice Insertion Product / CVC Type Delivery Set changes Skin Antisepsis Infusion Bag Changes Dressings Manipulations

63 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: Nonthrombotic Causes and Treatment. [Miscellaneous]." Home Healthcare Nurse March 21(3):

64 Types of Occlusions: Mechanical Non- Thrombotic Thrombotic Occlusion Partial: one-way valve effect Complete Reasons for Occlusion: Mechanical: Kink in the catheter Dislodged Huber Non-Coring needle Positional the catheter rests up against the vessel wall preventing flow Pinch-Off Syndrome 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 Complete occlusion of the vessel

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

66 Assessment Mechanical Non-Thrombotic Thrombotic Positional Flow Catheter Aerobics Can flush but cannot aspirate Patient can hear the ocean/gurgling sound Resistance to flushing Sudden Occlusion Types medications/ infusates delivered One-Way valve effect Extravasation Can t aspirate Catheter tip not in the SVC SVC Syndrome: Pain, tingling, swollen arm or neck to same side of port, venous distension, throat tightness Placement of port/catheter on Left side

67 Treatment of Occlusions What type of occlusion is it? What are your options? What are the risks? What are the benefits?

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70 Getting the drug in

71 Flushing

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73 Technology: Needleless Injection Bungs

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

75 Flush Considerations Flush solutions Heparin (100u/ml; 10u/ml) Normal Saline (NS) Volume Volume of catheter=volume of add-on devices X 2 Typically 2-10 cc (varies by institutional protocol) Frequency Intermittent infusion/locked catheter every 12-24h Before and after each drug is administered Continuous infusion: NS flush with each tubing change or daily Hadaway, L. M. R. N. C. C. (2006). "Technology of Flushing Vascular Access Devices. [Article]." Journal of Infusion Nursing May/June 29(3):

76 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.

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78 Quiz What are the three complications with vascular access? When do you flush a CVAD? How do you flush a CVAD? What type of bung is used at your hospital?

79 Securing a CVAD Suture Dedicated Securement Device Steri Strip

80 Dressing & Securement IV Specific Dressing Transparent (enables site assessment) Provides Securement of the Catheter

81 Dressing

82 Catheter Removal Removal by qualified individuals Removal procedure (sterile technique is used in many facilities) Scope of practice Acute catheters including PICCs Tunneled Catheters Implanted Ports

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