VENOUS ACCESS DEVICES CENTRAL LINES/CATHETERS, MIDLINE CATHETERS, IMPLANTED INFUSION DEVICES

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1 VENOUS ACCESS DEVICES CENTRAL LINES/CATHETERS, MIDLINE CATHETERS, IMPLANTED INFUSION DEVICES There are several different venous access devices with which prehospital personnel may come in contact. Many people now have home care for these devices or travel back and forth to doctors for the treatments for which these devices were implanted. It is important that the Paramedic know what to do and what NOT to do when caring for these patients. Types of Devices: Central lines, implanted Subclavian access is most common but can also be internal jugular or femoral. Used for long term IV therapy, antibiotic therapy, pain management, chemotherapy, blood draws Central catheter, peripherally inserted (PICC line) Inserted from the cephalic vein, basilica vein or brachial vein and catheter is run up to vena cava Used for same purposes as subclavian access central line Midline catheter Inserted from a vein just below the antecubital space run up to where the tip lies just below the axilla Used for shorter term access for fluids, antibiotics, etc. but can remain in place much longer than standard IV access Implanted infusion device

2 Port a Cath, MediPort, implanted infusion pumps usually implanted in the chest wall, contains a reservoir to allow injections of medications into the device for delivery and may reside in the patient for years Same long term treatments as central lines but also can be used for insulin and other medications POSSIBLE COMPLICATIONS OF THESE DEVICES: Anticoagulation Stasis Embolus formation Infection Malfunctioning devices Air embolus Patients with these types of devices are typically chronically ill and immunoimpaired. This places them at an extremely high risk of sepsis if the device is contaminated in any way, including access to the device using non-sterile technique. Central line devices also provide direct access to the major vasculature and heart, so air embolus is also extremely possible if the line develops a leak or is open to allow access with syringe for drug or fluid administration or to draw blood. IF you must utilize one of these devices, it is absolutely imperative that you use sterile technique and that you clamp the line before inserting a needle into the port or removing the cap and again before removing the needle or replacing the cap. (Caps from these lines also must be handled and placed where they will not be contaminated.) USING A CENTRAL LINE TO DRAW BLOOD, GIVE MEDS OR ESTABLISH AN IV 1. Ensure that you have medical control permission to use the site. If initiating an IV line in a non-arrest situation, look for other IV sites FIRST. 2. Use sterile technique at all times.

3 3. Draw two 10 cc syringes of normal saline (or more if giving multiple drugs). 4. Clamp the tubing above the port. 5. If the port is covered with a cap, remove the cap and place into an empty alcohol prep package to maintain sterility while performing the procedure. If establishing an IV line, you want to ensure the cap is readily available for an emergency so consider folding down the top of the package containing the cover and taping onto the head of the stretcher in plain site. If the line has an injectable port, clean the port with an alcohol prep. 6. If drawing blood, attach and empty syringe to the port, unclamp and draw 5 cc of blood. Reclamp, discard this syringe, attach another sterile syringe to draw the amount of blood you need for the blood samples, unclamp and draw the blood. Reclamp, remove that syringe and attach a syringe with the NS you have drawn, unclamp and flush the line. (Reclamp prior to removing the syringes in each step and reclamp the line at the end of the procedure before removing the final syringe.) Recap if a cap was over the port prior to laying the line down on any nonsterile surface. If injecting medications or establishing an IV line, attach the syringe, unclamp, then flush the line first with one of the syringes in which you have NS. Reclamp before removing the syringe and then attach the medication syringe or IV line before unclamping. Once the medication is administered or if the IV line is to be DC d, reclamp prior to removing the syringe or line. Recap the line if a cap was over the port prior to laying the line down on any non-sterile surface.

4 ACCESSING AN IMPLANTED VENOUS ACCESS DEVICE Consider this route in a life threatening situation or arrest only in the field. Peripheral IV sites should be attempted first. 1. Ensure that you have medical control permission to use the site. 2. Prepare equipment including the draw of two or more syringes with at 5 cc of NS each. 3. Palpate the skin over the device. You should feel the surface as soft and rubbery to allow needle access and for it to close again after the needle is removed. A small gauge hypodermic needle or butterfly needle should be used. 4. Cleanse the site thoroughly. Use Betadine if the patient is not allergic to this substance. Use a circular motion going out. 5. Prime the needle with the medication or, if using a butterfly needle/tubing to attach an IV line, be sure to prime it. 6. Without breaking sterile technique, insert the needle at a 90 degree angle to the skin until you feel the needle tip touch the back of the device. 7. Aspirate 5 cc of blood first to ensure patency. Discard. You may then draw more blood from site if performing phlebotomy. 8. Flush the device with a syringe with 5cc NS after blood draw, administer medications or attach IV line. Be sure to flush the device after each medication administration or after DC of the IV line. 9. Be sure to secure the needle at the site and place a sterile dressing over the site. SIGNS/SYMPTOMS OF SERIOUS COMPLICATIONS Embolism

5 Sudden onset of chest pain, shortness of breath, tachycardia, hypotension, altered LOC, shock Management: Aggressive airway management, treat shock, immediately place patient on left side and raise foot of stretcher or place in trendelenburg position if possible, treat cardiac arrhythmias as indicated by rhythm. Be sure to look for possible CAUSE of embolus s/s as it could be an air embolus from damage to the line or clamp or disconnected IV line. Correct immediately if found. Catheter thrombosis Swelling of arm, neck or shoulder with pain Management: Due to the risk of emboli, treat as for air embolus. Handle the patient gently to reduce risk of accidentally mobilizing emboli from site. Rapid transport. Occlusion Cannot aspirate blood or infusion won t run Management: Ensure that all clamps are open. Consider closing clamp, removing syringe or line and reattaching a syringe with 10 cc NS, flush, reclamp, and then try again. If this does not resolve problem, you should DC attempts to use the port until it is evaluated at the hospital. Rapid transport. Sepsis Fever, chills, very sick, may show signs of septic shock Management: High flow oxygen, airway management, treat for shock. Rapid transport. Catheter breakage or leak in catheter line Bleeding at site if catheter is involved. Tubing is damaged or broken and can have signs/symptoms of air embolus.

6 Management: Control bleeding with direct pressure using sterile technique and sterile dressings. Bleeding may be severe. Treat for shock. If line is impaired, clamp above the break. If the existing clamp is below the line break, use hemostats padded with 4x4 s above the line break. 4x4 s are necessary to prevent the hemostats from breaking the line again.