Management of Central Venous Access Devices (CVADs) Bangkok June 2015 Venous Access Devices Implantable Port Central Venous Catheter (CVC) Boviac /Hickman catheters Margaret Conway BSN, RN, CPON Peripherally Inserted Central Catheter (PICC) http://mattemery.net/curingjanice/?p=128 Outline Purpose and Placement Assessment and Complications Flushing Dressings Trouble shooting Central Venous Catheters (CVC) Purpose Long term IV access Meds (esp. irritants), Chemo, TPN, blood products, blood drawing Placement Placement: Surgical placement, Interventional Radiology or IV team PICC certified nurses Assessment Observe & assess site every hour. Flush lines prior to giving irritants to assess for patency and assess for blood return. If unable to flush line, check clamp, check for kinks in line. Assessment Check for signs of infiltration, phlebitis, infection Leaking or pain take dressing down to look. If infiltration observed, stop infusion, assess for break in line document on flow sheet. Notify doctor for all above. 6 1
Complications http://www.medicaljournals.se/acta/content /?doi=10.2340/00015555 0420&html=1 7 INS Extravasation Guidelines 8 Infiltration Site edematous, hard, painful to touch. Fluid may be leaking from site Extravasation Site edematous, hard, painful to touch. Fluid may be leaking from site. See Children s Oncology Group (COG) guidelines Available on COG website with membership Infusion Nursing Society (INS) Guidelines (Next Slide) European Oncology Nursing Society EONS http://www.cancernurse.eu/documents/eonsclinicalguidelinessection6 en.pdf Alexander, M. et al. (2010). Infusion Nursing Society: Infusion Nursing an Evidence Based Approach 3 rd edition. St. Louis, MI: SaundersnElsevier Complications Infiltration Site edematous, hard, painful to touch. Fluid may be leaking from site Infection Site red, warm, may have purulent drainage Thrombophlebitis Same signs as infection, may have red streaking Case Study Thrombophlebitis 10 https://www.scripps.org/articles/90 9 superficial thrombophlebitis What is Phlebitis or Thrombophlebitis? 11 Phlebitis: The inflammation of the intima of the vein, creating a rough wall where platelets readily adhere Thrombophlebitis: Is a two fold injury with the presence of a thrombus and the occurrence of inflammation Case Study 61 y.o. male with Stave IV gastric cancer with plural metastasis Implanted port placed for chemotherapy Chemo regimen included Docetaxel infusion (no complications with line) Paclitaxel and Ramucirumab (phlebitis along line) 12 2
Case Study: INS recommendations to prevent phlebitis Use in line filters Use recommended solutions or diluents when mixing medications Dilute known irritating medications to the lowest concentration Administer intravenous push medications through a port of a compatible free flowing infusion Case Study: INS recommendations to prevent phlebitis (continued) Administer medications or solutions at the minimal rate recommended Rotate peripheral sites at recommended intervals Use large veins for the administration of hypertonic or acidic/alkaline solutions to provide more hemodilution Use smallest gauge catheter that will adequately deliver ordered therapy Alexander, M. et al. (2010). Infusion Nursing Society: Infusion Nursing an Evidence Based Approach 3 rd edition. St. Louis, MI: SaundersnElsevier 13 14 Case Study: INS recommendations to prevent phlebitis (continued) Avoid areas of flexion Adequately secure catheter to prevent catheter from moving in and out of site Strict hand hygiene to prevent bacterial phlebitis Aseptic technique in preparation of venipunture sites and catheter insertion Frequent site observation to notice early signs of phlebitis Alexander, M. et al. (2010). Infusion Nursing Society: Infusion Nursing an Evidence Based Approach 3 rd edition. St. Louis, MI: SaundersnElsevier Case Study: Paclitaxol Paclitaxol: A novel antimicrotubule agent. Disrupts cell cycle at many different phases Administration of Paclitaxol: Can be administered over a 3 hour infusion or a 24 hour infusion Dilute to final concentration 0.3 1.2mg/ml Use a 0.22 micron filter on administration set Injection site reactions more frequent with 24 hour infusion vs. 3 hour infusion http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/020262s049lbl.pdf 15 16 Case Study: Ramucirumab Vascular endothelial growth factor 2 antagonist Inhibits angiogenesis Used in gastric cancers Administration: Only compatible with 0.9% sodium chloride Final dilution 250 ml Use 0.22 micron filter Administer over 60 minutes no IV push or bolus Do not co infuse with other solutions http://pi.lilly.com/us/cyramza pi.pdf Case Study How did this phlebitis occur? Debilitated patient? Poor vein condition? Ineffective filtration? Hypertonic or acidic solutions? Improperly diluted Too rapid infusion? 17 18 3
Case Study Next steps: Consult with doctor or surgeon Consider line study if available Is there a partial occlusion, fibrin sheath? Initial phlebitis treat with ice packs then heat DO NOT massage can dislodge clot Use alternate sites until problem can be diagnosed www.cathflo.com 19 Complications Full or Partial Occlusion 21 Use of tissue plasminogen activator tpa (Doctor MD order required) Dosing Alteplase ( http://www.cathflo.com/dosing/index.jsp ) DOSAGE AND ADMINISTRATION Cathflo Activase (Alteplase) is for instillation into the dysfunctional catheter at a concentration of 1 mg/ml. Patients weighing 30 kg: 2 mg in 2 ml Patients weighing <30 kg: 110% of the internal lumen volume of the catheter, not to exceed 2 mg in 2 ml Not compatible with heparin Let dwell for up to 120 minutes may repeat x1 DO NOT exceed 4mg Catheter types Know what type of catheter your patient has. Valved catheters: has a valve within the catheter that when not in use prevents the back flow of blood into the catheter and reduces risk of air embolism. Preservative free saline is only required for flushing. Catheter Example: Groshong Non valved catheters require intermittent low concentration heparin 24 4
Flushing Using a 10 ml syringe flush with preservative free normal saline before/after meds SASH (Saline Antibiotic Saline Heparin) method Flush using pulsating motion push, stop, push, stop method Helps to keeps line clear prevents clotting Reduces biofilm build up in catheter Decreases bacterial build up in catheter Ferroni, A. et al Medical Devices: Evidence and Research 7 November, 2014 2008 Infusion Nursing Society (INS) Guidelines for Flushing CVADS 26 Alexander, M. et al. (2010). Infusion Nursing Society: Infusion Nursing an Evidence Based Approach 3 rd edition. St. Louis, MI: SaundersnElsevier Needless Connectors Caps Ongoing Education to Minimize CLABSI caps contaminated with strep epidermis then scrubbed with alcohol Positive Pressure Cap Negative Pressure Cap Neutral Pressure Cap Know what type your hospital uses All prevent back flow of blood into catheter Technique used to flush varies depending on type of cap Seconds Count! Scrub the hub with alcohol for 15 seconds prior to all line entries Kaler, W., Chinn, R. Journal of the Association of Vascular Access 2007 12(3) pp140-142 27 Flushing a Central Line 29 Catheter Site Dressing Regimens 2011 CDC guidelines Grady et al Use either sterile gauze or sterile, transparent, semipermeable dressing to cover the catheter site If the patient is diaphoretic or if the site is bleeding or oozing, use a gauze dressing until this is resolved Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled http://www.shop3m.com/ 30 5
Catheter Site Dressing Regimens 2011 Center for Disease Control (CDC) guidelines Grady et al Do not submerge the catheter or catheter site in water. Showering should be permitted if precautions can be taken to reduce the likelihood of introducing organisms into the catheter (e.g., if the catheter and connecting device are protected with an impermeable cover during the shower) Replace dressings used on short term CVC sites every 2 days for gauze dressings. Catheter Site Dressing Regimens 2011 CDC guidelines Grady et al Replace dressings used on short term CVC sites at least every 7 days for transparent dressings, except in those pediatric patients in which the risk for dislodging the catheter may outweigh the benefit of changing the dressing. Replace transparent dressings used on tunneled or implanted CVC sites no more than once per week (unless the dressing is soiled or loose), until the insertion site has healed. 31 32 Catheter Site Dressing Regimens 2011 CDC guidelines Grady et al Do not use topical antibiotic ointment or creams on insertion sites, except for dialysis catheters, because of their potential to promote fungal infections and antimicrobial resistance No recommendation can be made regarding the necessity for any dressing on well healed exit sites of long term cuffed and tunneled CVCs. Unresolved issue Catheter Site Dressing Regimens 2011 CDC guidelines Grady et al Use a chlorhexidine impregnated sponge dressing for temporary short term catheters in patients older than 2 months of age if the CLABSI rate is not decreasing despite adherence to basic prevention measures, including education and training, appropriate use of chlorhexidine for skin antisepsis No recommendation is made for other types of chlorhexidine dressings. Unresolved issue 33 34 Chlorhexidine Products 35 Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives BE PATIENT, wait for skin to dry completely before applying dressing Use with caution on patients who are diaphoretic or in an area that may become wet Venous Access Device Care All Implantable Port and CVC and PICC dressings are done maintaining sterile technique Dressings and sited to be assessed every hour while infusing Report any redness pain swelling or irritation to doctor as needed 6
How to Wash your Hands 37 Washing Hands With Hand Sanitizer 38 Dressing CVC Routine dressing changed using sterile technique Q 7 days unless loose, damp or soiled. Chloraprep For patients 37 weeks gestation: dry site 30 sec, wet site 2 min. For patients < 37 weeks gestation: Thoroughly wipe the site with alcohol 3 times. Allow the alcohol to dry for 1 minute. For infants 28 weeks gestation: wipe off the alcohol with sterile normal saline Why Chloraprep? Rapid activity against gram positive and gramnegative bacteria Persistent antibacterial activity prevents regrowth of microorganisms on the skin for at least 48 hours One application of ChloraPrep exceeds FDA criteria for a patient preoperative skin preparation antiseptic Unlike povidone iodine, ChloraPrep (CHG) remains active in the presence of blood, serum, and other protein rich biomaterials BE PATIENT, wait for it to dry thoroughly Skin Barriers and Securement Devices 41 Changing a CVC Dressing 42 7
Implantable Port Accessing the Port Purpose: Long term IV access Benefits No home maintenance Can shower, bathe Dressing Accessing an Implanted Port Change the safety needle a minimum of every 7 days minimum. Site must be rotated with each access. Change the dressing when the needle is changed, or if the dressing becomes loose. The dressing must be occlusive. 46 Peripherally Inserted Central Catheter (PICC) PICC Dressing Change 48 8
CVC Cap Change Cap change not more often then every 72 hours. Exclusions: Once every 24 hours for infusions with Blood products Liposomal preparations Lipids Ambisome Propofol CVC Cap Change 49 CVC Cap Change Questions? Videos How to flush a central line https://www.youtube.com/v/zswwy8wsczm How to was your hands https://www.youtube.com/v/yfp8xb3_lpc How to use a hand sanitizer https://www.youtube.com/v/hmgqqhurbi8 CVC dressing change https://www.youtube.com/v/ivjy8uroddu Implanted port video: https://www.youtube.com/v/z_wcv2kcoyy PICC video https://www.youtube.com/v/whmgzfsfn2y Cap change video https://www.youtube.com/v/ivjy8uroddu Washing hands across the globe https://www.youtube.com/v/rcdx5sa8xf8 53 9