central line
TRANSCRIPT
![Page 1: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/1.jpg)
De La Salle – Health Sciences InstituteCollege of Nursing and School of Midwifery
Dasmarinas, Cavite
CENTRAL VENOUS LINES
Submitted by:Acar, Mylene
Burgos, Joyce MariCancio, Ana Krizia
Dolot, Rey IvanEncarnacion, Maurice Pam
Submitted to:Ms. Joyce Velasco
Date: July 2010CENTRAL LINE
![Page 2: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/2.jpg)
I. Definition
A central line is also called a central venous line or a central venous catheter (CVC).
A catheter (tube) that is passed through a vein to end up in the thoracic(chest)
portion of the vena cava (the large vein returning blood to the heart) or in the right
atrium of the heart.
A central line is a catheter placed into a large vein. Most commonly used veins are
the internal jugular vein, the subclavian vein and the femoral vein.
A central line saves having to have frequent small injections or "drips" placed in the
arms. A central line may also allow a patient to have medicine or fluids at home
instead or in the hospital.
The central line may be inserted for the short term or long term. There are two types
of long term central lines: the cuffed or tunnelled line and the reservoir long line that
ends in a rubber bulb or reservoir.
The possible complications of a central line include air in the chest (pneumothorax)
due to a punctured lung, bleeding in the chest (hemothorax), fluid in the chest
(hydrothorax), bleeding into or under the skin (hematoma) and infection. If the line
becomes disconnected, air may enter the blood and cause problems with breathing
or a stroke.
II. Description and Common Features
A central line is a long, hollow tube made from silicone rubber. They are also called
skin-tunnelled central venous catheters. Examples of some of the makes that are
used are Hickman® or Groshong®.
The central line is inserted (tunnelled) under the skin of your chest into a vein. The
tip of the tube sits in a large vein just above your heart.
The space in the middle of the tube is called the lumen. Sometimes the tube has two
or three lumens. This allows different treatments to be given at the same time.
(Dependent on its use, the catheter is monoluminal, biluminal or triluminal,
dependent on the actual number of tubes - 1, 2 and 3 respectively.)
![Page 3: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/3.jpg)
The catheter is usually held in place by a suture and an occlusive plaster.
Regular flushing with saline or a heparin-containing solution keeps the line patent
and prevents infection.
At the end of the tube outside the body each lumen has a special cap to which a drip
line or syringe can be attached.
Sometimes there is also a clamp to keep the tube closed when it is not being used.
Common Features
Central Venous Catheter reduces the risk and vascular trauma due it
specially formulated and biocompatible Polyurethane material which provides
strength during insertion and also softens at body temperature to conform to the
body tissue
Soft Flexible J-Tip Guide wire provides good torque to ensure firm insertion
and also prevents vessel perforation
Specially designed soft & beveled tip for smooth & easy insertion of catheter
Clear and definite marking facilitates correct placement of catheter tip
Radio-opaque Catheter
Individually tray packed
Also available with the option of Guided Syringe or T-Type Introducer
Tube Length available : 160-200 mm, 300 mm
Complete set of CVC kit consists of :
Indwelling catheterCatheter holderCatheter holder clampExtension line clamp
![Page 4: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/4.jpg)
Injection capIntroducer needleJ-Tip guide wireLuer lock syringeScalpelVessel dilator
INDWELLING CATHETER
GUIDE WIRE NEEDLE DILATOR SYRINGE
Description O.D. (FR) / Ga (I.D.)
Length( mm )
Diameter O.D.( inch / mm )
Length( cm / mm )
O.D. (FR) /Length ( mm )
Single Lumen 3061
5 FR / 16 G (D)
1600.032 / 0.81
45 / 450
18 G6 Fr / 100 mm
5 cc200 45 / 450
300 60 / 700
Double Lumen 3062
7 FR / 16 G (P) - 16 G (D)
1600.032 / 0.81
45 / 450
18 G8 Fr / 100 mm
5 cc200 45 / 450
300 60 / 700
Triple Lumen 3063
7 FR / 18 G (P) / 16 G (D) / 18 G (M)
160
0.032 / 0.81
45 / 450
18 G8 Fr / 100 mm
5 cc200 45 / 450
300 60 / 700
http://www.suru.com/cvc.htm
III. Uses
1. A central line can be used to give you treatments such as chemotherapy , antibiotics
and intravenous fluids.
2. It can also be used to take samples of your blood for testing.
3. Central lines can also be used to give liquid food into the vein if your digestive
system is not able to cope with food for any reason.
4. A central line allows concentrated solutions to be infused with less risk of
complications.
5. It permits monitoring of special blood pressures including the central venous
pressure, the pulmonary artery pressure, and the pulmonary capillary wedge
pressures.
![Page 5: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/5.jpg)
6. The central line can be used for the estimation of cardiac output and vascular
resistance. The near end of the catheter may also be connected to a chamber for
injections given over periods of months.
You can go home with the central line in place and it can be left in for weeks or months.
This makes it possible for you to have your treatment without having to have needles
frequently put into your veins. This may be very helpful if doctors and nurses find it
difficult to get needles into your veins, or if the walls of your veins have been hardened
by previous chemotherapy treatment.
IV. Indications and Containdications
Indication
Monitoring of the central venous pressure (CVP) in acutely ill patients to quantify fluid
balance
Long-term intravenous antibiotics
Long-term parenteral nutrition especially in chronically ill patients
Long-term pain medications
Drugs that are prone to cause phlebitis in peripheral veins (caustic), such as:
Calcium chloride
Chemotherapy
Hypertonic saline
Potassium chloride
Amiodarone
Plasmapheresis
Dialysis
Frequent blood draws
Frequent or persistent requirement for intravenous access
Need for intravenous therapy when peripheral venous access is impossible
Blood
![Page 6: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/6.jpg)
Medication
Rehydration
Central venous catheters usually remain in place for a longer period of time,
especially when the reason for their use is longstanding (such astotal parenteral
nutrition in a chronically ill patient). For such indications, a Hickman line, a PICC
line or a portacath may be considered because of their smaller infection risk. Sterile
technique is highly important here, as a line may serve as a porte d'entrée (place of
entry) for pathogenic organisms, and the line itself may become infected with
organisms such as Staphylococcus aureus and coagulase-negative Staphylococci.
Central venous pressure is considered a direct measurement of the blood pressure in
the right atrium and vena cava. It is acquired by threading a central venous catheter
(subclavian double lumen central line shown) into any of several large veins. It is
threaded so that the tip of the catheter rests in the lower third of the superior vena cava.
The pressure monitoring assembly is attached to the distal port of a multilumen central
vein catheter.
The CVP catheter is an important tool used to assess right ventricular function and
systemic fluid status.
Normal CVP is 2-6 mm Hg.
CVP is elevated by :
o overhydration which increases venous return
o heart failure or PA stenosis which limit venous outflow and lead to venous
congestion
o positive pressure breathing, straining,
CVP decreases with:
o hypovolemic shock from hemorrhage, fluid shift, dehydration
o negative pressure breathing which occurs when the patient demonstrates
retractions or mechanical negative pressure which is sometimes used for
high spinal cord injuries.
![Page 7: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/7.jpg)
The CVP catheter is also an important treatment tool which allows for:
Rapid infusion
Infusion of hypertonic solutions and medications that could damage veins
Serial venous blood assessment
Parenteral nutrition (PN) is feeding a person intravenously, bypassing the usual process
of eating and digestion. The person receives nutritional formulas
containing salts, glucose, amino acids, lipids and added vitamins. It is called total
parenteral nutrition (TPN) when no food is given by other routes.
Phlebitis is an inflammation of a vein, usually in the legs. When phlebitis is associated
with the formation of blood clots (thrombosis), usually in the deep veins of the legs, the
condition is called thrombophlebitis. These clots can travel to the lungs,
causing pulmonary embolisms which can be fatal.
Chemotherapy is the use of chemical substances to treat disease. In its modern-day
use, it refers almost exclusively to cytostatic drugs used to treat cancer. In its non-
oncological use, the term may also refer to antibiotics (antibacterial chemotherapy).
Calcium chloride is an irritant, particularly on moist skin. Dry calcium chloride
reacts exothermically when exposed to water. Burns can result in the mouth
and esophagus if humans or other animals ingest dry calcium chloride pellets. Small
children are more susceptible than adults (who generally have had experience trying to
eat hot food, and can react accordingly) so calcium chloride pellets should be kept out
of their reach.
Hypertonic saline is used in treating hyponatremia and cerebral edema. Due to
hypertonicity, administration may result in phlebitis and tissue necrosis. As such,
concentrations greater than 2% NaCl should only be administered via a central venous
catheter. It is commonly available in two strengths:
3% NaCl has 513 mEq/L of Na and Cl.
![Page 8: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/8.jpg)
5% NaCl has 856 mEq/L of Na and Cl.
Potassium Chloride may cause pain and thrombophlebitis if administered in high
concentration into small veins.
IV intermittent - for urgent potassium replacement:
Peripherally:
o Maximum 20 mEq/250 mL administered over 1 hour
Central line:
o General Nursing Units: Maximum 20 mEq/100 mL over 1 hour;
o Cardiac Sciences (C10AB, CD) may administer maximum of 20
mEq/50mL over 1 hour
o Critical/Special Care Areas: Maximum of 40 mEq/100 mL over 1 hour
IV infusion:
Peripheral Line: Usual concentration: 20-40 mEq/L; Maximum: 80 mEq/L, infused
at a maximum rate of 10 mEq/hour
Central Line: Usual concentration: 20-60 mEq/L; infused at a maximum rate of 20
mEq/hour
Amiodarone belongs to a class of drugs called Vaughan-Williams Class IIIantiarrhythmic
agent. It is used in the treatment of a wide range of cardiac tachyarhthmias, including
both ventricular and supraventricular (atrial) arrhythmias. The chemical name for
amiodarone is 2-butyl-3-benzofuranyl 4--3,5-diiodophenyl ketone hydrochloride.
Plasmapheresis is the removal, treatment, and return of (components of) blood
plasma from blood circulation. It is thus an extracorporeal therapy. The method can also
be used to collect plasma for further manufacturing into a variety of medications. During
plasmapheresis, blood is initially taken out of the body through a needle or previously
implanted catheter. Plasma is then removed from the blood by a cell separator.
![Page 9: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/9.jpg)
D ialysis (from Greek "dialusis", meaning dissolution, "dia", meaning through, and "lysis",
meaning loosening) is primarily used to provide an artificial replacement for lost kidney
function in people with renal failure. A central line is necessary when you need drugs
given through your veins over a long period of time, or when you need kidney
dialysis. In these cases, a central line is easier and less painful than having needles put
in your veins each time you need therapy.
Blood is a circulating tissue composed of fluid plasma and cells (red blood cells, white
blood cells, platelets). Medical terms related to blood often begin in hemo- or
hemato- (BE: haemo- and haemato-) from the Greek word "haima" for "blood". The
main function of blood is to supply nutrients (oxygen, glucose) and constitutional
elements to tissues and to remove waste products (such as carbon dioxide and lactic
acid). Blood also enables cells (leukocytes, abnormal tumor cells) and different
substances (amino acids, lipids, hormones) to be transported between tissues and
organs. Problems with blood composition or circulation can lead to downstream tissue
dysfunction.
M edication is a licensed drug taken to cure or reduce symptoms of an illness or medical
condition. Medications are generally divided into two groups -- over the counter (OTC)
medications, which are available in pharmacies and supermarkets without special
restrictions, and Prescription only medicines (POM), which must be prescribed by
a physician. Most OTC medication is generally considered to be safe enough that most
persons will not hurt themselves accidentally by taking it as instructed. However, the
precise distinction between OTC and prescription depends on the legal jurisdiction.
Medications are typically produced by pharmaceutical companies and are
oftenpatented. Those that are not patented are called generic drugs.
Rehydration is the replenishment of water and electrolytes lost through dehydration. It
can be performed by mouth (oral rehydration) or by adding fluid and electrolytes directly
into the blood stream (intravenous rehydration). As oral rehydration is less painful, less
invasive, less expensive, and easier to provide, it is the treatment of choice for
![Page 10: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/10.jpg)
mild dehydration from infectious gastroenteritis. Because severe dehydration can
rapidly cause permanent injury or even death, intravenous rehydration is the initial
treatment of choice for that condition.
http://en.wikipedia.org/wiki/Central_venous_catheter
http://www.spiritus-temporis.com/central-line/indications-and-uses.html
Contraindications
Uncooperative patient
Uncorrected bleeding diathesis
Skin infection over the puncture site
Distortion of anatomic landmarks from any reason
Pneumothorax or hemothorax on the contralateral side
Positive end-expiratory pressure (PEEP) mechanical ventilation
Only one functioning lung
http://note3.blogspot.com/2004/02/central-line-placement-procedure-guide.html
V. Types
1. Non - Tunneled Central Catheters
Non Tunneled central catheters are used for short-term(less than 6 weeks) IV
therapy in acute care, long-term care and home care settings. The physician inserts
these catheters. Examples of non-tunneled catheters are Vas Cath, percutaneous
subclavian Arrow and Hohn catheters. The subclavian vein is the most common vessel
used, because the subclavian area provides stable insertion site to which the catheter
can be anchored, allows the patient freedom of movement and provides easy access to
the dressing site. The jugular vein should only be used as a last resort and then only for
1 to 2 days. The 16-gauge distal lumen can be used to infuse blood or other viscous
![Page 11: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/11.jpg)
fluids. The 18-gauge middle lumen is reserved to PN infusion. The 18-gauge proximal
port can be used for administration of blood or medications. A port not being used for
fluid administration can be used for obtaining blood specimens if indicated.
If a single-lumen central catheter is used to administer PN, various restrictions
apply. Blood cannot be drawn from the catheter and transfusions of blood products
cannot be given through the main line, because red blood cells may coat the lumen of
the catheter, thereby reducing the flow of the nutritional solution. Medications also
cannot be administered through it, because it may be incompatible with the components
of the nutritional solution (insulin is an exception). If medications must be given, they
must be infused through a separate peripheral IV line, not by piggyback into the PN line.
Insertion
The procedure is explained so that the patient understands the importance of not
touching the catheter insertion site and is aware of what to expect during the insertion
procedure. The patient is placed in supine in the Trendelenburg position (to produce
dilation of neck and shoulder vessels, which makes entry easier and prevents air
embolus). The area is shaved if necessary, and the skin is prepared with acetone and
alcohol to remove surface oils. Final skin preparation includes cleaning with tincture of
2% iodine or chlorhexidine. To afford maximal accuracy in the placement of the
catheter, the patient is instructed to turn the head way from the site of venipuncture and
to remain motionless while the catheter is inserted and the wound is dressed. The
preferred insertion route is the subclavian vein, which leads into the superior vena cava.
The external jugular route can be used, but usually only in emergency situations.
Because a non-tunneled central catheter is always a potential source of serious
infection, the insertion site should be changed every 4 to 6 weeks or as recommended.
Full-length sterile drapes are applied. Procaine or lidocaine is injected to
anesthetize the skin and underlying tissues. The target area is the inferior border at the
midpoint of the clavicle. A large-bore needle on a syringe is inserted and moved parallel
![Page 12: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/12.jpg)
to and beneath the clavicle until it enters the vein. The syringe is then detached and a
radiopaque wire is inserted through the needle into the vein. The catheter us then
advanced over the wire, the needle is withdrawn, and the hub of the catheter is attached
to the IV tubing. Until the syringe is detached from the needle and the catheter is
inserted, the patient may be asked to perform VALSALVAmaneuver. (The patient is
instructed to take a deep breath, hold it, and bear downwith mouth closed.) The
Valsalva maneuver is performed to produce a positive phase in central venous
pressure, thereby lessening the possibility of air being drawn into the circulatory system.
The physician sutures the catheter to the skin to avoid inadvertent removal.
The catheter insertion site is swabbed with either tincture of 2% iodine or a
chlorhexidine solution. A gauze or transparent dressing is applied using strict sterile
technique. An isotonic IV solution, such as dextrose 5% in water is administered to keep
the vein patent. The position of the tip of the catheter is checked with x-ray or
fluoroscopy to confirm its location in the superior vena cava and to rule out
pneumothorax resulting from inadvertent puncture of the pleura. Once the catheter’s
position is confirmed, the prescribed PN solution is started. The initial rate of infusion is
usually 50ml/hr and the rate is gradually increased to the maintenance rate or
predetermined dose. An infusion pump is always used for administration of PN.
And injection site cap is attached to the end of each central catheter lumen,
creating a closed system. IV infusion tubing is connected to the insertion site cap of the
central catheter with a threaded needleless adapter or Luer-lok device. Each lumen is
labelled according to the location. To ensure patency, all lumen are flushed with diluted
heparin flush initially, daily when not in use, after each intermittent infusion, after blood
drawing, and whenever an infusion is disconnected. Force is never used to flush the
catheter. If resistance is met, aspiration may restore lumen patency; if this is not
effective, the physician is notified. Low-dose tissue plasminogen activator (altepalse)
may be prescribed to dissolve clot or fibrin sheath. If attempts to clear the lumen are
ineffective, the lumen is labelled as “clotted off” and not used again.
![Page 13: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/13.jpg)
Care of Non Tunneled Central Catheter
1. Hand washing: always wash your hands with soap and water before touching the
central line or the area around it.
2. Activity guidelines: do not go swimming.
3. Central line may need to be flushed: it can be saline, heparin or both; flushing is
done to help prevent the catheter from getting blocked. It also helps to prevents
mixing of medicines with each other in the tubing.
Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11 th Edition) Volume 1.
Lippincott William and Wilkins.
2. Peripherally Inserted Central Catheter
- Used for intermediate long term care IV therapy that could last for several days up to
months.
- Done in hospital or home setting.
- It is inserted at Basilic and Cephalic vein through the antecubital space.
- The catheter is threaded to a designed location depending on the type of solution to
be infused. (E.g. Superior vena cava for parenteral nutrition)
- Solutions that can be infused through this method include total parenteral nutrition,
chemotherapy regimens and extended antibiotic therapy.
- Taking of blood samples and blood pressure are contraindicated.
- Length of the catheter ranges from 30-65cm.
![Page 14: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/14.jpg)
3. Tunneled Central Catheter
- It is used for long term care and may remain in place for years.
- The catheters have cuffed and can have single or double lumens. ( E.g. Hickman,
Groshong, Permacath)
- Inserted to vein at one location tunneled under the skin to a separate exit where it
emerges from underneath the skin. It is held in place by a Dacron cuff, just
underneath the skin at the exit site. Exit is located in chest making access ports less
visible than if they were directly protruded from the neck.
- Passing of the catheter under the skin prevents infection and provides stability.
The Hickman catheter
![Page 15: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/15.jpg)
It is softer than a simple triple-lumen catheter, and is usually inserted in an
operating room. The actual access to the subclavian vein is still by puncture under the
clavicle, but the distal end of the catheter is pulled under the skin for 2-4 inches and
comes out of the chest close to the nipple. This creates a "tunnel" which decreases the
risk of infection. These catheters can stay in place for weeks to months.
The Groshong catheter
It is very similar to the Hickman catheter, but has a valve at the tip of the catheter
which makes it unnecessary to leave a high concentration of heparin in the catheter
(see below). The Broviac catheter is also similar to the Hickman catheter, but is of
smaller size. This catheter is mostly used for pediatric patients
4. Implanted Ports
- Implantable Ports are catheters which are inserted completely under the skin.
- The distal end of the catheter is formed by a small metal "drum" or reservoir, which
has on one side a membrane for needle access. This drum is surgically placed
under the skin, just below the clavicle, with the membrane immediately below the
skin. The catheter runs from the drum into the subclavian vein. Access is always
with a special needle that is pushed through the skin and the membrane into the
reservoir inside the drum. Such ports come in different sizes, and can have either
![Page 16: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/16.jpg)
one or two lumens. Since the entire catheter is under the skin, the risk of infection is
smaller than with external catheter
VI. INSERTION AND REMOVAL OF CENTRAL CATHETERS
INSERTION OF CENTRAL CATHETERS
Prior to the procedure
Adhere to institutional Policy and Procedure.
Obtain history and assess the patient.
Explain the procedure to the patient, include:
local anesthetic
trendelenberg positioning (to produce dilation of neck and shoulder
vessels, which makes entry easier and prevents air embolus).
turn the head away from the site of venipuncture and to remain
motionless while the catheter is inserted and the wound is dressed for
maximal accuracy
draping
limit movement
need to maintain sterile field.
post procedure chest X-ray
Obtain the catheter size, style and length ordered.
Obtain supplies:
Masks
![Page 17: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/17.jpg)
Sterile gloves
Line insertion kit
Heparin flush per policy
Position patient supine on bed capable of trendelenberg position
Prepare for post procedure chest X-ray or fluoroscopy
1. Nontunneled Central Catheters
The area is shaved if necessary, and the skin
is prepared with acetone and alcohol to
remove surface oils. Final skin preparation
includes cleaning with tincture of 2% iodine
or chlorhexidine.
The preferred insertion route is the
subclavian vein, which leads into the superior
vena cava. The external jugular route can be
used, but usually only in emergency
situations.
Full length sterile drapes are applied.
Procaine or lidocaine is injected to
anesthetize the skin and underlying tissues.
The target area is the inferior border at the
midpoint of the clavicle.
A large-bore needle on a syringe is inserted
and moved parallel to and beneath the
clavicle until it enters the vein.
![Page 18: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/18.jpg)
The syringe is then detached and a radiopaque
wire is inserted through the needle into the
vein. The catheter is then advanced over the
wire, the needle is withdrawn, and the hub of
the catheter is attached to the IV tubing. The
physician sutures the catheter to the skin to
avoid inadvertent removal.
The catheter insertion site is swabbed with either tincture
of 2% iodine or a chlorhexedine solution. A gauze or
transparent dressing is applied using strict sterile
technique. An isotonic IV solution, such as dextrose 5%
in water (D5W), is administered to keep the vein patent.
The position of the tip of the catheter is checked with x-
ray or fluoroscopy to confirm its location in the superior
vena cava and to rule out pneumothorax resulting from
inadvertent puncture of the pleura. Once the catheter’s
position is confirmed, the prescribed parenteral nutrition
solution is started. The initial rate of infusion is usually 50 mL/hour, and the rate is
gradually increased to the maintenance rate or predetermined dose (eg, 100 to 125
mL/hour). An infusion pump is always used for administration of parenteral nutrition.
An injection site cap is attached at the end of each
central catheter with a threaded needleless adapter or
Luer-Lok device. Each lumen is labeled according to
location (proximal, middle, distal). To ensure patency, all
lumens are flushed with a diluted heparin flush initially,
daily when not in use, after each intermittent infusion,
after blood drawing, and whenever an infusion is disconnected. Force is never used to
flush the catheter. If resistance is met, aspiration may restore lumen patency; if this is
![Page 19: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/19.jpg)
not effective, the physician is notified. Low-dose plasminogen activator (alteplase) may
be prescribed to dissolve a clot or fibrin sheath. If attempts to clear the lumen are
ineffective, the lumen is labeled as “clotted off” and not used again.
Because a nontunneled central catheter is always a potential source of infection, the
insertion site should be changed every 4 to 6 weeks, or as recommended by the latest
CDC guidelines.
2. Peripherally Inserted Central Catheters
Basilic or cephalic vein inserted through the antecubital space, and catheter is threaded
to a designated location, depending on the type of solution to be infused.
The insertable portion of a PICC varies from 35 to 60 centimeters in length, that being
adequate to reach the desired tip position in most patients. Some lines are designed to
be trimmed to the desired length before insertion. Others are simply inserted to the
needed depth with the excess left outside. As supplied, the line has a guide wire inside.
This wire is provided to stiffen the (otherwise very flexible) line so it can be pushed
through the veins. The wire is removed and discarded after insertion.
3. Tunneled Central Catheters
![Page 20: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/20.jpg)
These catheters are inserted surgically. They are threaded under the skin to the
subclavian vein and the distal and of the catheter is advanced to the superior vena
cave.
Your neck will be checked for a suitable
vein using a small ultrasound machine.
The area where the line is to be inserted
is cleaned with an antiseptic solution.
A local anaesthetic is used the numb the
area. Pain would not be felt during the
insertion, but a bit of soreness is usually
felt for a few days afterwards.
A small cut is made in the skin near the clavicle and the tip of the tube is threaded into a
large vein. This is known as the insertion site. The tube is then pushed under the skin to
reach the exit site.
Chest x-ray is ordered to make sure that the tube is put in the right place.
The position of the exit site will vary from person to person. The nurse or the physician
can inform the patient where on the chest the exit site is likely to be.
When the tube has been put in, dressings are applied aseptically to cover the insertion
and exit sites. For a few days, the patient may feel pain or discomfort under the skin
where the tube has been tunnelled. A mild painkiller such as paracetamol will help to
ease this.
4. Implanted Ports
![Page 21: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/21.jpg)
Instead of exiting from the skin, the end of the catheter is placed in a subcutaneous
pocket, either on the anterior chest wall or on the forearm.
The port is surgically implanted beneath the
skin, and generally in the chest region. The
incision is made halfway between the clavicle
and nipple on either the left or right side of the
chest. The right side of the chest is generally
preferred since the vein curves down more
directly to the superior vena cava. The surgeon
makes the final decision about the site for
implantation based on skin condition, presence
of a pacemaker, and taking into account other
medical conditions that would contra-indicate
the use of a particular site. An approximate 5-
cm incision in the skin is made at the selected
site. A “kangaroo” pocket is created approximately two inches away from the incision
line and 0.5-cm to 2.0 cm deep into which the portal body is placed. The pocket is
located away from the incision line in order to avoid rupturing the incision with
subsequent accessing of the port. The implanted port is placed in this pocket and
sutured in place to the underlying tissue.
The suturing should be secure enough so that the implanted port won’t loosen with
frequent accessing and manipulation of the port. The underlying tissue should be firm in
order to provide support to the implanted port for accessing and de-accessing. The
catheter is connected to the portal body at the shoulder of the implanted port Catheters
separate from the portal body are pushed over the barb and the catheter locked in place
with a radiopaque ring. The catheter is then threaded subcutaneously from a point near
the clavicle to meet with the portal body. The catheter tip is advanced into the
subclavian vein and terminated in the superior vena cava/atrial junction. It takes
![Page 22: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/22.jpg)
approximately two weeks for the body to establish a “healed in tract” for the tunneled
catheter.
This procedure takes from one-half to one-hour and generally a local anesthesia is
used.
Other sites used for the placement of implanted ports are in the abdominal cavity with
the tip of the catheter tunneled into the inferior vena cava. The breast may also be used
for implanted port placement in female patients. These sites provide less stability to the
port when accessed than does the chest location.
VII. REMOVAL OF CENTRAL CATHETERS
1. Nontunneled Central CathetersAND Peripherally Inserted Central Catheters
A nurse will usually does this in an outpatient department. It will be gently pulled out.
This is a painless procedure that takes only a few minutes.
2. Tunneled Central Catheters
Patient will lie on a bed. The chest is cleaned with antiseptic. The area around the cuff is
numbed with local anaesthetic. A small cut is made to gently release the cuff and the line is then
removed slowly. This can feel uncomfortable, but it should not be painful.
A dressing will be put over the exit site and patient will be asked to remain lying down (for about
10 minutes) until it is certain that there is no bleeding.
3. Implanted Ports
This is usually done by a doctor who will use a local anaesthetic to numb the area. Sometimes
the port will be removed under a general anaesthetic.
The doctor will make a small incision over the site of the port and remove it. The catheter will be
pulled out of the vein. The wound is then stitched and covered with a small dressing.
Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11th Edition).
Lippincott William and Wilkins.
![Page 23: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/23.jpg)
http://nursinglink.monster.com/training/articles/302-the-use-and-maintenance-of-
implanted-port-vascular-access-devices
http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/
Treatmenttypes/Chemotherapy/Linesports/Implantableport.aspx
http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/
Treatmenttypes/Chemotherapy/Linesports/PICCline.aspx
http://www.macmillan.org.uk/Cancerinformation/Cancertreatment/
Treatmenttypes/Chemotherapy/Linesports/Centrallines.aspx
VIII. Care of Central Venous Catheter
• Do not let the CVC exit site get wet until it is well healed. Client may shower 72 hours
after the catheter has been inserted. When bathing or showering, cover the site with
waterproof material, such as household plastic wrap, taped over the dressing and
injection caps.
• Do not submerge the CVC site or caps below the level of water in a bathtub, hot tub,
or swimming pool.
• Store CVC supplies in a clean, dry place such as a shelf in a closet or a drawer.
• Always clean the work area with alcohol and let it to dry completely before setting up
the supplies or cover the area with clean paper towels.
• Use only sterile supplies. Open all packages carefully without touching the contents.
Handle dressings only at the edges.
• Never touch the open end of the CVC when the cap has been removed.
• Never touch the end of the needleless cannula or the end of the open syringe. If this
happens accidentally, use a new cannula or syringe.
• Never use scissors, pins, or sharp objects near the CVC or other tubing. The catheter
could be damaged easily.
• If the catheter has a clamp, keep it clamped when not in use. Some CVCs show where
the clamp must be placed. If CVC does not show the clamp location, ask nurse to show
where to clamp.
• Remember to wash hands thoroughly before and after working with the CVC.
![Page 24: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/24.jpg)
Changing the CVC dressing
The CVC dressing is changed every 7 days if you are using a transparent
dressing. Change it every 48 hours if using gauze or Telfa island dressing and tape. If
the dressing becomes wet or loose, change it even if it is not the normal time to change
it. A nurse will give specific instructions the type of dressing.
Flushing of catheter with a clamp
Some CVCs have separate tubes. Each tube is called a lumen. Each lumen of
the CVC needs to be flushed regularly to keep it clear of backed-up blood. If you have
more than 1 lumen, it is helpful to have a routine for flushing lumens in the same order
each time. For instance, you might always flush the red one first, then the white, then
blue. You will flush each lumen of the CVC once a day using 3 cc of heparin solution
(100 units heparin/cc), unless you have been instructed differently.
Flushing of Groshong catheter
Groshong catheters are flushed once a week or when the catheter is used. The
lumens are flushed using 10 cc of saline solution on the same day of each week.
Heparin is not used because of the special construction of the Groshong catheter.
Central venous catheter cap changes
The injection cap on each lumen of your CVC is changed every 5 to 7 days. Change a
cap any time it is leaking.
Problems encountered:
Accidental removal of the CVC from the
chest
Apply pressure to the exit site and chest
area above it with a gauze dressing or
clean washcloth. Call the immediately.
![Page 25: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/25.jpg)
Accidental removal of injection cap
Make sure that the CVC is clamped. Clean
the outside threaded area of the lumen
with an alcohol wipe for at least 30
seconds. Place a new cap securely into
the open end. If you do not have a new
cap, wrap the end of the lumen with sterile
gauze until you can get a cap. Flush
catheter following the usual steps.
Damage to the CVC, such as a hole or
crack in the tubing
Immediately clamp the CVC between the
hole and chest. If necessary, pinch or fold
it over to clamp it. Cover the hole or crack
with sterile gauze.
Difficulty flushing the catheter
Make sure the CVC is unclamped. Change
position by raising the arms, lying down,
sitting up more straight, coughing, or
taking a deep breath. If you still cannot
flush it, stop using the catheter and call the
doctor immediately.
Loose suture at exit site Tape the CVC to the skin. Notify physician.
IX. Possible complications of Central Lines
Infection
![Page 26: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/26.jpg)
It is possible for an infection to develop either inside the central line or around the exit
site. Watch out for:
the exit site when it becomes red or swollen or painful
discolored fluid coming from it
development of fever or chills
swelling of the face, neck, chest, or arm on the side where your catheter is inserted
displacement or lengthening of the catheter
Client will be given antibiotics, but if these do not clear the infection from the line it may
have to be removed.
Blood clots
It is possible for a blood clot (thrombosis) to form in the vein at the tip of the line. If a clot
does form, client will be given some medication to dissolve the clot and line may have to
be removed.
Arrhythmias
Arrhythmia may occur during the insertion process when the wire comes in contact with
the endocardium. It typically resolved when the wire is pulled back.
Pneumothorax
Central line insertion outweighs the risk for pneumothorax. It is for central lines placed in
the chest. No air must be allowed to get into the central line. The clamps should always
be closed when the line is not in use. The line must not be left unclamped when the
caps (bungs which are at each end of it and stop air from passing through it) are not in
place. Groshong lines do not have clamps; they have a special valve inside the line
instead.
![Page 27: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/27.jpg)
Complications of Parenteral Nutrition
Complications:
Pneumothorax
Cause:
- Improper catheter
placement and inadvertent
puncture of the pleura
Treatment:
Place patient in
fowler’s position
Offer reassurance
Monitor vital signs
Prepare for
thoracentesis or
chest tube insertion
Air embolism - Disconnected tubing
-Blocked segment of
vascular system
Replace tubing
immediately and
notify physician
Turn patient on left
side place in the
head-low position.
Notify physician.
Clotted catheter -Inadequate/infrequent
heparin flushes
Administer heparin
flush in unused lines
twice a day
Catheter displacement and
contamination
-Excessive movement Stop the infusion and
notify the physician
Sepsis -Separation of dressing
-Separation of tubing and
contamination
Monitor vital signs
every 4 hours
Reinforce dressing
quickly using aseptic
technique
Hyperglycemia -Glucose intolerance Administer insulin as
orderly
Fluid overload -Fluid infusing rapidly Decrease infusion
rate
![Page 28: Central Line](https://reader034.vdocuments.us/reader034/viewer/2022051515/552669794a7959ce488b4ecf/html5/thumbnails/28.jpg)
Monitor vital signs
Notify physician
Rebound hypoglycemia -Feedings stopped too
abruptly
Monitor for
symptoms
(weakness, tremors,
diaphoresis,
headache, hunger
and apprehension)
http://www.upmc.com/HealthAtoZ/patienteducation/Documents/CVC.pdf
http://en.wikipedia.org/wiki/Central_venous_catheter
Smeltzer, S.C, et. al. (2008). Medical Surgical Nursing (11 th Edition) Volume 1.
Lippincott William and Wilkins.
♥ In God We Trust. ♥