your mission…. prevention and early detection!!!!! quality improvement evidence-based practice...

Your Mission….

Prevention and Early Detection!!!!!

Quality Improvement

Evidence-based practice

Teamwork and Collaboration

Safety “minimize risk of harm to patients and

providers through both system effectiveness and individual performance”

1

Indications

Long-termCaustic medsTPN (dextrose content > 10%)Monitor RA pressuresDialysisMultiple therapiesNo peripheral accessFrequent blood sampling

2

What’s in a Name?

Central Venous Access Device (CVAD)CVCCentral lineBy type (percutaneous)TLC (triple lumen catheter), PICC

By sitesubclavian, jugular, femoral

By brand name (tunneled)Broviac, Hickman, Groshong, Mediport

3

What’s the Difference?

Similarities

Tip of catheter in a “central” vein:• Superior vena

cava

Differences

How/where it is inserted

Length of stay

4

Method 1: Percutaneous

Needle stick, through skin, directly into vein.Central (7 days-Phillips)PICC (> 7 days to several months)

Single, double, or triple lumen

Triple: proximal, medial, distal ports

5

PICC linePeripherally Inserted Central Catheter

6

7

Tunneled

Surgical procedure

Very long-term

Exit site: chest or abdominal wall

Examples:HickmanGroshong Implanted port (medi-port)

8

9

CVAD Insertion

Supplies : Check P&P

tray

antiseptic solution

Dressing material

CONSENT

10 cc Syringes w/ NS

Needleless caps

“time out” check list

Patient Teaching r/t insertion

Purpose

Position: flat, Trendelenberg

keep hands down

face covered

turn head away

10

Complications of CVAD

Pneumothorax

Malposition

SVC syndrome

Occlusions

Infection

Air Embolism

Unintentional disruption

11

Central Venous Catheter Complications — Pneumothorax, Hemothorax, Chylothorax

CauseDuring insertion of CVC, introducer may

cause traumaPneumothorax (collection of air in the pleural

space due to trauma to lung)Hemothorax (collection of blood in pleural

cavity)Chylothorax (transection of the thoracic duct

causes lymph fluid to enter the pleural cavity)

12

Central Venous Catheter Complications: Pneumothorax

Treatment early detection: CXR after insertionOxygen Monitor vital signsPressure should be applied over the vein

entry siteRemove the catheterChest tube if appropriate

13

Obstruction – Prevention is Key

Positive Pressure Displacement device

Flush unused ports per protocol

‘Push-Pause’ technique

Check solution for precipitates

Filter if indicated

14

Flushing a CVAD

10 mL syringe or larger

Aspirate for blood return before flushing (INS,2006)

SAS or SASH (per hospital protocol) Groshong Catheter – saline only

“push – pause” techniqueQ 12 or 24 hours – per protocol

Positive pressure caps flush, remove syringe, clamp

15

Infection

CRBSI

Exit site infection

Catheter tract infection

Septic thrombophlebitis

16

Central Venous Catheter Complications: Catheter Related Blood Stream Infection

(CRBSI)

CauseBacteria or fungi in a patient who has a

intravascular device with positive blood culture

All BSIs that cannot reasonably be linked to a site of local infection are attributed to CVC

BiofilmContamination

17

Central Venous Catheter Complications:CRBSI (continued)

Prevention (National Patient Safety Goals)Strict sterile technique Implementation of bundle approachTunneling and subcutaneous cuffsAntiseptic-impregnated dressingColonization-resistant polymersContamination-resistant hubsLuminal antimicrobial flush/lock solutionsGood hand hygieneFrequent site assessment

18

CR-BSI “bundle”

Hand hygiene

Maximum barrier precautions “time out” during insertion prn

Chlorhexidine gluconate site disinfection

Optimal catheter site (avoid femoral vein)

Daily review of line necessity – remove when no longer medically indicated.

19

Systemic Complication: Venous Air Embolism (VAE)

CauseAllowing the solution container to run dry and

then hanging a new bagLoose connections that allow air to enter

systemPoor technique in dressing and tubing

changes for central linesPresence of air in administration set

Factors that must be present:direct communication with source of airPressure gradient

20

Systemic Complication: Venous Air Embolism (VAE)

Signs and symptomsPatient complains of palpitationsLightheadedness and weaknessPulmonary: dyspnea, cyanosis, tachypnea,

expiratory wheezes, coughCardiovascular findings: “mill wheel”

murmur; weak, thready pulse; tachycardia; substernal chest pain, hypotension

Neurologic findings: change in mental status, confusion, coma

21

Systemic Complication: Venous Air Embolism (VAE) (continued)

PreventionPurge all air from administration setsUse 0.22 micron air-eliminating filterFollow protocol for dressing and tubing

changes for central linesAttach piggyback meds to the proximal

injection portUse Luer-Lok connectorsDo not bypass the “pump housing” of EIDsAfter removal of central lines initial dressing

should be occlusive

22

Systemic Complication: Venous Air Embolism (VAE) (continued)

TreatmentCall for help and notify physician immediatelyOnce VAE is suspected, any central line

procedure in progress should be stopped; clamp line

Place in Trendelenburg position on left sideAdminister oxygenMaintain systemic arterial pressure with fluid

resuscitation and vasopressorsMonitor vital signs If circulatory collapse initiate CPR

23

CVAD Dressing Change

Prevention of infection is dependent upon

1. effectively reducing the number of microorganisms on the skin

2. Limiting access of the microorganisms to the catheter site.

24

Discontinuing a CVAD

Only for percutaneous

Position: Trendelenburg

Valsalva maneuver during removal

Apply pressure

Pressure dressing

25

Drawing blood from a central line(Dominican procedure)

Turn off IV solutionsFlush w/10 mL NSWithdraw 5 mL “discard”Use syringe or vacutainer to withdraw desired amt. bloodFlush w/ 20 mL NSLabel specimens “line draw”

26