Vascular Access Via Central Catheter Educational Module

Vascular Access via Central Catheter New Hampshire Division of Fire Standards and Training and Emergency Medical Services

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Terminal Objective  At

the completion of this training the NH Paramedic will be given the skills to access existing central catheters with safe aseptic technique for life threatening conditions with clear indications for immediate use of medications or fluid bolus.

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Enabling Objectives  

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Explain the insertion sites for the various catheter types. Describe the general principles, indications, precautions, equipment, technique and complications of vascular access via existing central catheters Discuss infection, medical asepsis and the differences between clean and sterile techniques. Describe the use of universal precautions and body substance isolation (BSI) procedures when accessing existing central catheters.

Enabling Objectives    

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Comply with universal precautions and body substance isolation (BSI). Defend a management plan for vascular access via an existing central catheter. Serve as a model for medical asepsis and sterile technique. Serve as a model for disposing. contaminated items and sharps.

Enabling Objectives 

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Identify various types of venous access devices List at least three types of mechanical occlusions. Use universal precautions and body substance isolation (BSI) procedures during medication administration.

Enabling Objectives  Demonstrate

aseptic and sterile technique during vascular access via an existing central catheter.  Demonstrate preparation and administration of parenteral medications.  Identify signs and symptoms of infiltration  Identify improperly accessed devices 6

Introduction  Central

Venous Catheters (CVCs) were once reserved for the acutely ill patient, with advances in medical technology, all types of CVCs are being utilized.

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Examples of CVC uses – – – – – – – – –

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Parenteral fluids Caustic Medications eg. chemotherapy Long term pain management Blood and blood products Long-term Antibiotics Total parenteral nutrition (TPN) Patients requiring frequent or repeated blood sampling (Catheters greater than 4 FR) Pressure monitoring Potassium

Types of Vascular Access Devices  Non-tunneling  Tunneling  Implanted

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Non-Tunneling  Direct

venipuncture through the skin into a selected vein. – – –

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Peripheral VADs Peripherally inserted central VADs Percutaneous catheters

Non-Tunneling-Peripheral VADs  Butterfly – –

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& angiocaths

Short catheters generally placed in forearm, hand or scalp veins Short term therapy and unable to handle caustic chemicals (chemotherapy)

Non-Tunneling - PICC  Peripherally

inserted central catheters (PICC)

 Midline  Central

venous catheter inserted at or above the antecubital space and then advanced until the distal tip of the catheter is positioned at the superior vena cava or superior vena cava and right atrial junction.

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Non-tunneling - PICC 

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Useful for patient receiving long term medication therapy, chemotherapy or TPN Used for frequent blood sampling Distal end positioned at the superior vena cava or superior vena cava and right atrium

Non-Tunneling - PICC  Peripherally

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inserted central catheters (PICC)

Non-Tunneling - Midlines  Used

for shorter term intravenous therapy (up to 4 weeks)  Used for frequent blood sampling  Distal end positioned at the proximal end of the upper extremity 15

PICC versus Midline

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Non-Tunneling – PICC and Midline examples at the antecubital & above

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Non-Tunneling – CVC  Percutaneous

catheters  Also known as: Central Venous Catheters (CVC) – –

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Subclavian or internal jugular Single, double or triple lumen

Non-tunneling - CVC 

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Tip advanced to superior vena cava and right atrium As with PICC, appropriate for patients requiring long term chemotherapy or TPN

Non-tunneling CVC subclavanian site

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Tunneling  Hickman®  Broviac®  Groshong®

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Tunneling  Inserted

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into a central vein via percutaneous venipuncture or cut down  Catheter then tunneled under the skin in the subcutaneous tissue and exited in a convenient location  Dacron cuff hold the catheter in place

Tunneling - Hickman®

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Tunneling - Broviac®  Similar

to the Hickman catheter, but is of smaller size.  This catheter is mostly used for pediatric patients.

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Tunneling - Groshong®  Similar

to Hickman® and Broviac® with closed ended patented 3-way valve.

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Implanted VADs - Ports 

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Catheter attached to a self-sealing silicone septum surrounded by a titanium, stainless steal or plastic port Port sutured under the skin

 Some – – –

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brand names:

Port-a-cath® Infus-a-port® Power Port ®

Implanted VADs - Ports 

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Catheter runs from port to superior vena cava at the right atrium No part of the device is exposed outside the body Can deliver chemotherapy, TPN, antibiotics, blood products and blood sampling

Implanted VADs - Ports 

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Can only be accessed with special needle called a HUBER needle Contains a deflecting, non-coring point

Apheresis/Hemodialysis Catheter  Indicated

for use in attaining long and short term vascular access for hemodialysis or apheresis therapy

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Ready for a break?

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Insertion Complications  Inadvertent

Arterial Puncture  Hematoma Formation  Extravasation  Infection  Phlebitis  Pneumothorax

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Systemic Complications  Infection  Deep

Vein Thrombosis  Pulmonary Embolism  Superior Vena Cava Syndrome

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Mechanical Complication  Catheter

tip migration  Broken or damaged catheter  Catheter occlusion

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Risk of Infection  Good

aseptic technique must be utilized to help prevent infection.  The preferred method would be to utilize sterile technique whenever possible.  BSI

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Infection  Infection-

invasion of the body by pathogenic microorganisms and the reaction of tissues to their presence and to toxins generated by the organisms

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Infection Process  Involves – – –

three stages

Invasion Localization/Containment Resolution

 Infection

may revert back or become worse at any stage of the process

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Infection Process - Invasion  Invasion

- introduction of pathogenic microorganisms into the tissue –

May be result of violating aseptic or sterile technique during wound preparation or medical procedure.

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Poor skin/ wound preparation of a contaminated wound

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Other routes

Infection Process – Localization/Containment  The

inflammatory response is the body's initial defense directed toward localization and containment of the infecting organism  RBC’S, WBC’S, and Macrophages infiltrate the tissue with possible abscess formation  The body attempts to ward off the abscess by building a membrane encapsulating the tissue or cells 39

Infection Process - Resolution  Depends

on immunological responses capable of overcoming the infectious process  Associated with drainage and removal of foreign material, including debris of bacteria and cells, lysis (disintegration) of microorganisms, reabsorption of exudate, and sloughing of necrotic tissue 40

Factors that Contribute to Infection 

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Infection results from the interaction between three elements: organisms, tissues, and host defenses –

Organism - size and virulence have to do with the microbes ability to cause disease

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Tissue - the condition of the tissue is significant; necrotic, devitalized, avascular tissue or the presence of blood or foreign bodies provide an excellent media for pathogenic growth

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Host defense - the general health of the patient influences resistance to microbial invasion

Aseptic  Aseptic

technique is a set of specific practices and procedures performed under carefully controlled conditions with the goal of minimizing contamination by pathogens

 1:

preventing infection 2: free or freed from pathogenic microorganisms

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Sterile

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Free from living organisms and especially microorganisms

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Sterility will apply to SELECT surfaces of objects or to substances that will be introduced into a patient’s body. Some objects just don’t have the potential to be made sterile. Hands can be made very clean but not sterile. Gloves from the dispenser are not sterile, nor are surgical masks. The message is: Only specific, deliberately prepared surfaces or substances are considered sterile.

Aseptic Technique  Barriers

are established to control the spread of microorganisms by:

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Protecting sterile areas

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Isolating surgical wounds

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Keeping free microbes to a minimum

Aseptic Technique  Skin –

Washing with soap (antimicrobial) before and after patient contact

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NOTE: It is important to note that even under emergency conditions, all steps necessary to maintain asepsis should be taken.

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Donning gloves

 Mouth –

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and nose

A mask should be worn People with respiratory tract infections should

Aseptic Technique - continued  Fomites

- nonliving material such as bed linen that may transmit microorganisms

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Should be packaged and stored properly

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Clean and soiled supplies should be physically separated

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Prompt decontamination of used equipment and reusable supplies

Sterile Technique

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NOTE: Aseptic techniques control microorganisms in the environment, sterile techniques prevent transfer of microorganisms into the body tissues.

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Need for sterile technique – Freshly incised or traumatized tissue is easily infected –

Intact skin is the body’s first line of defense against infection

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Any break in the integrity of the skin is a potential route of entry for infection

Sterile Technique

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Opening a sterile kit or tray

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Opening a sterile kit or tray - continued

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Putting on Sterile Gloves

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Putting on Sterile Gloves - continued

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Sterile Technique  The

following sterile technique slides refer to the hospital environment.  It is expected that the paramedic will adhere to the sterile technique outlined here as is reasonability possible in the pre-hospital environment.

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Sterile Technique - continued  NOTE:

If you have a question about the sterility of an item, consider it unsterile! When in doubt, throw it out!

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Sterile Technique - continued          

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Assembles needed equipment and supplies Washes hands Creates a sterile field Adds sterile items to sterile field Adds liquids to sterile field Puts on sterile gloves Maintains sterile technique while performing activities Removes gloves Disposes of gloves, supplies, and equipment Washes hands

Sterile Technique - continued  Gowns

are considered sterile only from the waist to the shoulder-level in the front, and the sleeves

 Sterile

people keep their hands in sight and above waist level

 Hands

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are kept away from the face, elbows are kept at the sides

Sterile Technique - continued  Tables

are considered sterile at table level

only – – –

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Only the top of a sterile draped table is considered sterile (edges and sides are not) Anything falling or extending over the edge of the table is considered unsterile Outer 1 inch edge of table top is considered unsterile

Sterile Technique - continued

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Only persons that are sterile touch sterile items

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Unsterile persons do not reach over a sterile field; sterile persons avoid leaning over a sterile field.

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The sterile field is created as close as possible to the time of use. The degree of contamination is proportional to the time the sterile items are exposed to the environment.

Sterile Technique - continued  Sterile

areas are continuously kept in view. Avoid turning your back to a sterile field, or walking between two sterile fields.

 Integrity

of the sterile package is destroyed if it is perforated, punctured, or contaminated with moisture

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Sterile Technique - continued  Skin

cannot be sterilized and is a potential source of contamination. Scrubbing, gowning, and gloving reduce the possibility of contamination to a minimum.

 Where

some areas cannot be scrubbed (i.e., mouth, nose, throat), masking reduces the risk of contamination

 Air

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is contaminated by dust and droplets. Environmental control measures must be employed to control this source of

Vascular Access via an Existing Central Catheter  Indications: –

In the presence of a life threatening condition, with clear indications for immediate use of medications or fluid bolus.

 Contraindications: – –

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Prophylactic IV access Suspected infection at skill site

Determine the catheter type  PICC  Midline  Broviac  Hickman  Groshong  Mediport

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Procedure for Peripherally inserted or Tunneled Catheters  PICC –

Some brand names: Cook, Neo-PICC, BD, Arrow, Bard

 Broviac  Hickman  Groshong

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Parts of the catheter

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Prepare your equipment     

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10 ml syringe (empty) 10 ml syringe (normal saline) Sterile gloves (if available Alcohol preps 250 – 1000 ml normal saline and administration set

Syringe WARNING  Do

NOT use syringes less than 10 ml.  Smaller syringes have greater pressure and could rupture the line, vessel and/or viscus

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More than one lumen  If

the catheter has more than one lumen, select the largest lumen

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You will not always be able to tell the largest.

Air Embolism WARNING  There

is a risk of air embolisms when a central IV line is open to the air.  Use a needle or utilize a needleless access system for medication administrations  Clamp the line whenever you remove the injection port cap to attach or disconnect a syringe or IV line. 70

Clamping end of the cap  Ensure

the clamp is properly secured

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Clamp

End cap

Prep end of lumen with alcohol swab

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Flushing    

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Using aseptic technique attach 10 ml syringe of normal saline Unclamp lumen Flush port with 3 - 5 ml of sterile normal saline to determine patency. If catheter does not flush easily (note PICC line will generally flush more slowly and with greater resistance than a typical IV catheter) re-clamp the selected lumen and try another lumen (if present) Re-clamp and discard syringe

If You Are Unable to Flush  Attach

the empty 10 ml syringe and unclamp the lumen  Aspirate 5 ml of blood.  Re-clamp and discard syringe with blood  If clots are present, contact medical control (MC) before proceeding.  Re-attempt to flush  If unable to flush, re-clamp and contact MC 74

Accessing & Administration 

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Attach IV administration set and observe for free flow of IV fluid. PICC line generally will not free flow and will need a pump Administer life saving medications or fluid bolus Watch for desired effects Reminder: You CANNOT give a rapid bolus through a PICC line

Fluid Administration  If

shock is not present, allow fluid to run at a rate of 10ml/hour to prevent the central line from clotting

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Maximum Flow Rates  The

maximum flow rates for a PICC line is 125 ml/hour for 3.0 Fr sized catheter or less and 250 ml/hour for greater.  Excessive flow rate can result in blowing out the tip of the catheter  You may need to check with manufacturer’s recommendations 77

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Blood Pressure  Avoid

taking a blood pressure on the same arm as a PICC

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Implanted Catheter  Use

sterile technique  Prepare equipment  Identify site (usually located in the chest)  Clean the access site with Choloprep (Alcohol and Betadine if allergic)  Allow the skin to air dry, if possible

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Attach 10 ml syringe to Huber needle

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Implanted Catheter

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Secure access point firmly between two fingers and advance Huber needle into port at a 90 degree angle

Implanted Catheter  Aspirate

3 – 5 ml of blood with the syringe.  If unable to aspirate blood, re-clamp the catheter and do not attempt further use.  If clots are present, contact medical control before proceeding.

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Implanted Catheter  Discard

blood filled syringe  Attached 10 ml syringe of normal saline and flush with 3 – 5 ml.  If catheter does not flush easily, re-clamp and do not attempt further use.

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Implanted Catheter  Attach

IV administration and observe for free flow of IV fluids  Administer life-saving IV medications as indicated  If shock is not present, allow fluid to run at a rate of 10 ml/hour to prevent the port from clotting. 85

Signs and Symptoms of Infiltration of an Implanted Catheter  Burning  Numbness/tingling

in the arm  May see fluid accumulation  If this occurs, discontinue and contact Medical Control

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Questions?

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Acknowledgements     

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Mello-Andrews, Rae, MS, RN, CEN, NREMT-P Doug Martin, NREMT-P Policies and Procedures for Infusion Nurses, 3rd Edition, INS, 2006 NH Medical Control Board. 2007 NH Patient Care Protocols, Version 2, January 2007 CDC, Morbidity and Mortality Weekly Report: Guidelines for the Prevention of Intravascular Catheter-Related Infections. August 9, 2002/Vol. 51/No. RR-10 University of North Caroline Hospitals. Nursing Procedures Manual: Central Venous Access Device: Subcutaeous Implanted Port (Port-ACath® Infus-A-Port®, Mediport®)-Accessing and General Information. October 2005 Cook Medical, Bloomington, IN Ohio State University Medical Center, Sterile Technique, June 2004