1/22/2016 - mmlearn.org · 1/22/2016 1 disclaimer •omnicare, inc., as a provider of infusion...

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Disclaimer

• Omnicare, Inc., as a provider of Infusion Pharmacy Services, is

committed to the establishment and maintenance of the highest

quality of care in infusion therapy services.

• This Infusion Therapy Education Program has been developed entirely

by Omnicare Infusion Services. This program is not meant to be used

alone or to replace the practicum necessary at the patient’s bedside

with an experienced clinician preceptor. This preceptorship is needed

to develop the skill set required to properly perform and administer

infusion therapy competently. Determining and documenting

competency is the responsibility of your employer.

Disclaimer

• Skills validation checklists are available in the Omnicare

Nurses’ Infusion Manual and electronically on Omniview, Omnicare’s

web portal.

• The nature of infusion therapy requires frequent updates. It is the

responsibility of the healthcare professionals involved with infusion

management to remain current in his/her practice.

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Disclaimer

• The practitioner is responsible for the exercise of independent skill and

judgment in the implementation of this information in the clinical setting.

This educational program is not intended to replace good professional

judgment by the healthcare provider nor is it intended to supersede the

necessity for clinically sound prerogatives of a healthcare organization.

• This education program was developed with reference to standards of

care and practice guidelines set forth by organizations such as The

Joint Commission, the Centers for Disease Control, the Infusion Nurses

Society, the Agency for Healthcare Research and Quality, and the

Institute for Safe Medication Practices, and USP 797. .

Vascular Access Devices

Choosing the most appropriate vascular access device for the therapy

will result in better clinical outcomes for the patient

Important Considerations When Selecting a Vascular Access Device

meds of extreme pHs


Catheter Types

Non extreme pH

Non extreme pH

900

900

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Features of Midlines and CVADs

Valved vs. Non-Valved Catheters

Vascular access devices may be valved or non-valved.

Valved catheters are manufactured with pressure sensitive

valves integral to the catheter. Midlines and all central vascular

access devices may be valved or non-valved.

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Valved Catheters

• Closed-ended valved catheter: Groshong®

‒ Slit valve near distal tip of catheter

‒ Three way pressure sensitive valve

‒ No heparin needed

‒ No clamp


Valved Catheters

• Open-ended valved catheter: PAS-V®, SOLO®

‒ Pressure sensitive valve is in hub

‒ No heparin needed

‒ No clamp


Non-Valved Catheters

• Distal tip open

• No pressure sensitive valve

• Requires heparin to prevent backflow of blood into catheter,

causing clot formation

Non-valved catheters

usually have clamps and

must be clamped at all

times when not in use!

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Power Injectable Catheters

• Power injectable catheters are designed to withstand the high

pressures associated with procedures requiring the use of

contrast media.

• Power rated catheters are manufactured using stronger grade

plastics that allow for infusion of solutions at rapid rates of up to

5 mL/second and compatible with pressures of up to 300 PSIs

required during contrast enhanced CTs.


Power Injectable Catheters (cont)

• PICCs, implanted ports, tunneled and non-tunneled catheters

may be rated for power injection

• External catheters rated for power injection may have a purple

hub, purple catheter and/or purple clamps to help identify them

as power injectable. Caution: not all power rated catheters

are purple. Other brands have the power rated clearly labeled

on the hub or other external part of the catheter.



• Power rated implanted ports may have raised tabs that can be

palpated on the septum to identify them as power rated ports

• In the LTC setting, catheters that are rated for power injections are

maintained and utilized the same as non-power rated catheters

• Regardless of power rating, follow prescribed flushing/locking

protocols for catheters according to catheter classification

• Power injectable catheters may be valved or non-valved. Follow

prescribed flush based on catheter type.

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Power Injectable Catheters • Power injectable catheters may be single or multi-lumen. The lumens

able to be used for power injections will be marked.

• Infusion of solutions or medications in power rated catheters shall not

exceed manufacturer’s recommendations for the medications or

solution being infused. For example: Vancomycin 1 Gram in 250 mL of

normal saline infused through a power injectable catheter would still be

infused over 90 minutes.

With all vascular access devices, information from the referring institution

is the best way to identify the type and brand of the catheter.




Midline Catheters

• Midline catheters may be made of silicone or polyurethane.

• Midlines may be inserted in the basilic, cephalic or brachial vein.

The midline catheter is then advanced into the larger vessels of

the upper arm with the distal tip terminating below the axillary

vein, but still in peripheral circulation.

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Midline Catheters

• Are between 8-20 cm long (3-8”)

• May be single or multi-lumen

• Require physician/LIP order for placement and reinsertion

• Informed, written consent is needed


Midline Catheters

extreme pH


Midline Catheters

Indications

• Therapies expected to last 1-4 weeks

• May be used for therapies appropriate for peripheral

administration

• Limited vascular access

• Nurse/physician/LIP/patient preference

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Midline Catheters

Care and Maintenance

• Change stabilization dressing/securement device 24 hours after

insertion, on admission, then every week and prn (every 2 days

if gauze dressing)

• Always use sterile technique during dressing changes

• If separate securement device is present, must be changed with

every dressing change

• Change needleless connector on admission, every 96 hours,

prn, and after blood transfusion

• Blood draws not recommended


Midline Catheters

Flushing/locking protocol:

If medication is incompatible with saline, consult with

infusion pharmacist for alternate flushing protocol

(i.e., D5W)


Midline Catheters

Tips When Utilizing Midlines for Infusion Therapy

• Always use aseptic technique when caring for or accessing catheter

• Flush immediately after intermittent infusion to prevent catheter

occlusion

• Use only appropriate flushing devices for flushing midline

• No BPs or blood draws on arm with midline

• Measure external catheter length upon insertion, and/or admission,

weekly with dressing change and prn

• If external catheter length increases, do not attempt to re-insert

catheter

• Midline measurement should be clearly documented in patient’s chart

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Midline Catheters

Tips When Utilizing Midlines for Infusion Therapy

• Thrombus may cause swelling of arm starting in the fingertips

• Midline insertion should be considered on the first day of therapy

• Midline insertion is not a STAT or emergency procedure

• Mechanical phlebitis can occur up to 72 hours post-insertion

• Mechanical phlebitis should be treated first, rather than immediately removing catheter

• Prevention of mechanical phlebitis:

‒ Warm compresses for 20 min QID x 2 days

‒ Elevate extremity

‒ Exercise arm gently


Midline Catheters


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Central Vascular Access Devices (CVAD)

Infusion catheters which are inserted into and dwell in the major

vessels of the body with the tip terminating in the superior vena

cava (SVC) or inferior vena cava (IVC).

Common to all CVADs

• May be valved or non-valved

• May be single or multi-lumen

• Physician/LIP order is required for placement and reinsertion

• Informed written consent is needed





Indications

• Poor peripheral access

• Therapies expected to last for several weeks, several months,

or several years • Phlebogenic/vesicant solutions/medications (e.g., Total

Parenteral Nutrition, Chemotherapy)

• Medical history contraindicating ongoing or intermittent

peripheral venipuncture

• Medical conditions requiring frequent venous access

• Emergency access

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Contraindications

• Thrombosis of subclavian, innominate or superior vena cava

(SVC)

• Anomalies of the central venous vascular structures



Classification of Central Vascular Access Devices

• 4 classifications ‒ Peripherally Inserted Central Catheter (PICC)

‒ Non-Tunneled Catheter

‒ Tunneled Catheter

‒ Implanted Venous Access Device Port

• Many different brand names

• Nurses must learn to identify by classification

• Nurses must identify if catheter is valved or non-valved

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Multiple Lumen Catheters

• Each lumen is a separate catheter and must be maintained

individually

• Allows for simultaneous administration of multiple

solutions/medications

• Allows for simultaneous administration of incompatible

solutions/medications



Considerations

• Blood draws allowed with physician/LIP order (for catheters 4 fr

or larger)

• Flush immediately after intermittent infusion to prevent clotting

• Maintain positive pressure when flushing

• All CVADs should be secured to prevent migration, or

advancement


Peripherally Inserted Central Catheter (PICC)

A PICC is a long, thin, flexible (silicone or polyurethane) catheter which

is inserted into a peripheral vein with the tip confirmed in the SVC.

• May be placed at bedside by PICC qualified RN or in Interventional Radiology

• Veins of choice for insertion: basilic, cephalic, brachial, or medial cubital vein

• Requires accurate, in depth patient assessment prior to placement

• 2008 SHEA/IDSA Practice Recommendation: Do not routinely replace

• 2016 INS Standards of Practice: No recommendation for dwell time

• Selective devices may be rated for power injection

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• Contraindicated for patients with history of dialysis shunt/fistula

• Avoid forearm and upper arm veins in patients with chronic

kidney disease stage 4 or 5, unless approved by patient’s

nephrologist, or physician/LIP if no nephrologist involved in care



Where is the tip supposed to be?

• According to national guidelines, the tip of a PICC must terminate in

the superior vena cava, not in the right atrium, subclavian, or

innominate (brachiocephalic) vein

• If not in the SVC, the tip is malpositioned and should be adjusted.

Adjustments are done under fluoroscopy or by a PICC qualified nurse.

‒ Tips in the subclavian and innominate veins have a higher risk of

thrombophlebitis development

‒ Tips in the atrium can lead to arrhythmias



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• Change stabilization dressing/securement device 24 hours after

insertion, on admission, then every week and prn (every 2 days

if gauze dressing)


• If separate securement device is present, must be changed

with every dressing change

• Change needleless connector on admission, every 96 hours,

prn, and after blood transfusion



• Flushing/locking protocol:



(i.e., D5W)



Tips When Utilizing PICCs for Infusion Therapy

• Do not administer medications through a PICC until tip

placement is confirmed

• Maintain catheter patency per flushing/locking protocol while awaiting tip confirmation

• Always use aseptic technique when caring for, or accessing, catheter

• No BPs or blood draws on arm with PICC

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Tips When Utilizing PICCs for Infusion Therapy (cont)

• Measure external catheter length upon insertion and/or

admission, with weekly dressing change and prn


catheter

• PICC measurement should be clearly documented in patient’s

chart




• Thrombus may cause swelling of arm starting in fingertips

• Insertion should be considered on the first day of therapy

• PICC insertion is not a STAT or emergency procedure

• Mechanical phlebitis can occur up to 72 hours post-insertion




• Mechanical phlebitis should be treated first, rather than

immediately removing catheter

• Prevention and treatment of mechanical phlebitis:

‒ Warm packs for 20 min QID x 2 days

‒ Elevate extremity

‒ Exercise arm gently

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Non-Tunneled CVAD

A non-tunneled central vascular access device

is a catheter that is percutaneously inserted

directly into a central vein with tip confirmed in

the SVC.

• Stiffer rigid polyurethane material

• Often sutured in place

• Shorter dwell time

• High infection rate

• Non-valved catheters should have a clamp

on external portion of catheter


Non-Tunneled CVAD

• Veins used for insertion: subclavian, internal

jugular, femoral

• If external catheter length increases, do NOT attempt to reinsert

• Copy of chest x-ray confirming tip location must be in medical

record prior to initial use in facility. If migration occurs, repeat

chest x-ray must be done to confirm new tip

location prior to use.

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Non-Tunneled CVAD


• Change stabilization dressing/securement device on admission then

every week and prn (every 2 days if gauze dressing)


If medication is incompatible with saline, consult with infusion

pharmacist for alternate flushing protocol (i.e., D5W)


Tunneled CVAD

A tunneled central vascular access device is a catheter that is

inserted into the subclavian or internal jugular vein with the tip

confirmed in the SVC and is then tunneled through subcutaneous

tissue and exits below catheter insertion site.

• Surgical procedure

‒ Dacron cuff in tunnel allows granulation tissue to form, creating an

anchor and barrier to prevent/resist bacterial migration

‒ Suture removal 10-14 days post insertion


Tunneled CVAD

• Initial post insertion assessment must include monitoring both

the insertion and exit sites


record prior to initial use in facility. If migration occurs, repeat

chest x-ray must be done to confirm new tip location prior to

use.

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Tunneled CVAD


• Change stabilization dressing/securement device on admission, every week and prn (every 2 days/gauze)


• If separate securement device is present, must be changed with every dressing change • Change needleless connector on admission, every 96 hours, prn, and after blood transfusion


Tunneled CVAD


• Measure external catheter length upon insertion and/or

admission, with weekly dressing change and prn


catheter


Tunneled CVAD




(i.e., D5W)

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Tunneled CVAD

Removal of a Tunneled Catheter is a Medical Act!

• Performed by physician/LIP

• Small incision over cuff may be necessary for removal


Implanted Venous Port

An implanted venous port is a catheter that is surgically placed into a blood

vessel and is attached to a reservoir. The tip terminates in the superior vena

cava (SVC).

• The reservoir is placed under the skin and has a self-sealing septum, or

diaphragm.

• The port is accessed using a percutaneous needle directly through the skin

and septum.

• Venous ports may be implanted in the chest or upper extremity. Once placed,

a port is completely covered by skin with no exposed parts.



• Stainless steel, titanium, or plastic reservoir with silicone septum connected to silastic catheter

• Self sealing septum allows multiple punctures

• Available in single or dual ports. A dual lumen port has two separate septums, reservoirs, and catheters.

• Most ports are placed in the chest and sutured into a subcutaneous pocket created by the surgeon located superficially above the breast tissue, although smaller ports may be implanted into the arm (e.g., P.A.S. Port® and X-Port™). If a patient has an implanted port in their arm, blood pressure cuffs and tourniquets should be avoided on the affected arm.

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• All ports require accessing/flushing/locking to maintain patency

• Insertion and removal requires surgical intervention

• Requires access with non-coring needle (e.g., Huber,

Miniloc®, SafeStep®)

• Less alteration in body image

• Less interference with normal ADLs

• No dressing required when not in use

• Long term use (years)



• Low maintenance when patient not on active infusion therapy

• Some implanted ports are rated for power injection. Since

power injections are not done in the LTC setting, these ports

may be accessed with regular, safety non-coring needles.





record prior to initial use in the facility

• If accessed: −Change non-coring needle and dressing every week

−Change dressing on admission, weekly and prn during active

infusion therapy (every 2 days if gauze dressing)

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• Always use sterile technique during non-coring needle/dressing

changes

• Flush/lock every month when not receiving infusion therapy, or

per physician/LIP orders








• If medication is incompatible with saline, consult with infusion

pharmacist for alternate flushing protocol (i.e., D5W)

• The nurse administering the locking must assess the

patient for any condition that may require a change in

concentration and/or volume of heparin

• Flush and lock immediately after intermittent infusion to prevent

catheter occlusion

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Port Specific Complications

• Port malposition – May be seen after there has been trauma to the

port body. One of the major complications that is seen when this

occurs is the port flipping over inside its subcutaneous pocket. The

nurse will not be able to access the port as the needle will be hitting the

bottom (back) of the port reservoir. Should this occur, surgical

intervention is needed.

If the non-coring needle becomes partially removed from the port body during active therapy, do NOT attempt to push the needle back into the septum of the

port. Instead, de-access and re-access per facility policy.




• Port erosion –May occur as a result of a misplaced non-coring

needle; improper needle length selection, or as a result from a

malnourished patient in negative nitrogen balance.




• Extravasation – A partially dislodged needle is the most common

reason for extravasation. Always assess the needle placement and

dressing integrity, especially when vesicants are infusing. In addition,

verify the presence of a brisk blood return. If swelling is noted during

an infusion, or patient has pain over port during an infusion, promptly

stop the medication, assess the patient and follow physician/LIP order

for extravasation, as needed.

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• Twiddler’s syndrome – This is a rare complication that can

occur due to the resident’s consistent manipulation of the port’s

body. This manipulation loosens, or breaks, the sutures which

were holding the implanted port’s body into the subcutaneous

pocket.



Assessments to be performed before accessing the port:

• Verify orders: for accessing/de-accessing; flushing

solutions/amounts/frequency; blood draws

• Ensure that the skin over the port is not inflamed, or showing s/s

of infection. Do not access if symptoms present, and follow up

with physician/LIP.

• Gently assess the mobility of the port

• Assess the depth of the port body to aid in determining the

needle length needed


Accessing an Implanted Port

• Always use sterile technique during port

access

• Perform hand hygiene

• Gather supplies on a clean work surface

• Open Port Access Kit

• Don masks

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Accessing an Implanted Port (cont)

• Add needleless connector and sterile

normal saline syringe to sterile field

• Don sterile gloves

• Prep site

• Attach needleless connector to non-coring

needle and prime with normal saline


• Stabilize port between thumb and

forefinger

• Insert non-coring needle into septum of

port, pressing firmly until needle touches

the back of the port

• Never rock or arc needle during

insertion

• Do not rotate or turn needle once

accessed


• Use proper length and gauge of non-coring needle

• Verify needle placement by aspirating for blood return

prior to initiating infusion

• Secure needle in place with transparent dressing to prevent

dislodging

• Coordinate change of non-coring needle with dressing change

every 7 days when port is accessed

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Tips for De-accessing

• Flush port with appropriate flush/lock solution prior to de-

accessing

• Always wear gloves when de-accessing a port

• Stabilize port with thumb and forefinger while de-accessing

• Remove needle slowly with a straight motion. Activate safety

feature per manufacturer’s instructions.


Maintenance of Vascular Access Devices

Dressing Change

• Change stabilization dressing/securement device on admission,

every week and prn (every 2 days if gauze dressing)

• Always use sterile technique during dressing change

• Perform hand hygiene and don clean

gloves and mask



Dressing Change

• Remove old dressing/securement device

• Perform hand hygiene at patient’s bedside using

appropriate cleansing agent. Don sterile gloves.

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Dressing Change

• Cleanse site

• Allow to air dry according to manufacturer’s instructions

(will take longer on hairy areas)

• Apply new securement device/stabilization dressing

• Measure external length of catheter, and mid-upper arm

circumference (one indicator of thrombus formation)

• Document dressing change



Needleless Connector Change

• Change needleless connector on admission, every 96 hours, prn, after

blood draws, and daily with parenteral nutrition. Note: Needleless

connector should be changed whenever blood enters the needleless

connector.

• Always prime needleless connector prior to connecting to catheter

• All lumens must have needleless connector changed at least every 96

hours



Needleless Connector Change

• Vigorously scrub connection with alcohol between hub and

needleless connector prior to needleless connector change

• Clamp catheter if appropriate

• Remove old needleless connector. ONLY cleanse open hub of

CVAD with alcohol if visible exudate/blood present.

• Attach new needleless connector to catheter hub

• Document needleless connector change

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Midline/PICC/Non-Tunneled CVAD Removal

• Physician/LIP order required

• May be removed by a qualified nurse per state regulation and

facility policy

• Locate catheter pre-insertion length documented on insertion

note. If not available, must obtain specific physician/LIP order to

remove catheter without knowledge of length.



• Place patient in supine position so that the IV insertion site is

below the level of the heart

• Don masks. Perform hand hygiene. Don clean gloves.

• Carefully remove stabilization dressing/securement device

• Perform hand hygiene. Don sterile gloves.

• Cleanse insertion site



• Remove sutures if present

• Apply antimicrobial ointment to sterile gauze

• Have patient perform Valsalva maneuver,

or take a deep breath and hold during

removal. Slowly pull catheter in short strokes

until removed. Do not stretch catheter!

• Apply gauze dressing with sterile antimicrobial

ointment over insertion site and apply pressure

until bleeding stops

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• Apply transparent dressing over gauze dressing

• Measure catheter and compare to length inserted

• Instruct patient to remain in supine position for 30

minutes

• Monitor site for bleeding through the dressing; every

15 minutes x 2; every hour x 2



• Document:

‒Reason for removal

‒Total catheter length

‒Site assessment

‒Interventions

• Leave dressing in place for 24 hours. Inspect and redress site

daily until site has epithelialized.


“Stuck Catheter”

If resistance is met during removal, STOP!

• Reposition arm and attempt to remove catheter

• If still unsuccessful, tape catheter loosely in place with sterile

tape. Apple new sterile dressing.

• Apply warm compress for 15 - 30 minutes to dilate vein

• Attempt again to remove catheter

• If resistance is met, notify physician/LIP

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Blood Sampling From Central Vascular Access Devices

• A physician/LIP order is required for blood sampling

• May only be performed by licensed nurse per state regulation

and facility policy

• Catheters/lumens smaller than 4 fr (18g) may be unreliable for

blood draws



• On multi-lumen catheters, the largest lumen is preferred for

blood withdrawal after all infusions have been stopped. If all

lumens are of equal size, and one is not red or brown, any

lumen may be used.



• Stop all infusions for at least one minute prior to blood draw.

• Disconnect the administration set and cover the end with a

sterile end cap.

• Prior to blood sampling, all infusions are stopped for at least one

minute.

• When a multi-lumen catheter is present, all infusions must be

stopped but only disconnect the administration set connected to

the lumen that will be used for blood withdrawal.

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• To avoid thrombotic and infection complications, waste blood must

NOT be reinfused

• Therapeutic drug levels may be specifically ordered to be drawn

peripherally

• Always check with the laboratory for the correct order in which to draw

the necessary lab work. The order of the draw may affect the results.

• Certain medications cannot be flushed through the CVAD (e.g., pain

management and inotropics)



• When drawing a sample for blood cultures: DO NOT discard the

blood from the first (aspirated) draw. Fill the blood culture tube

with aspirated blood from first draw. (Refer to Procedure 5.7

CVAD Culture)

• Avoid drawing blood from a heparinized CVAD for coagulation

studies

• Vacutainer system or syringe may be used to withdraw blood

from a CVAD



• The use of a syringe needle to transfer venous blood to a blood

collection tube or blood culture bottle is an OSHA prohibited

practice. The BD Vacutainer® Blood Transfer Device is a single

use device to reduce the risk of blood transfer related needle

stick injuries while maintaining the specimen integrity.

• Flush the catheter with 10 mL of NS prior to blood withdrawal to

confirm catheter patency and to remove any drug within the

catheter before the blood to be discarded is withdrawn

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• Approximately 5 mL of blood is withdrawn and discarded prior to

drawing blood for lab sample

• Smaller waste volumes are used for neonates, children, and frail

patients as ordered

• After blood withdrawal:

‒ Flush catheter with 10 mL NS to remove any residual blood



• Change primed, needleless connector. Flush with remaining 10

mL NS.

• Lock per protocol for vascular access device


If difficulty in obtaining sample:

• Have the patient sit up, lie down, turn from side to side, or ask

the patient to cough and reattempt to draw

• Caution: this may also indicate a problem with the catheter’s position

• If still unable to draw sample using a vacutainer, try using a syringe instead

• To obtain blood sample from a venous port, access the port with a larger, safety non-coring needle (20g) and verify placement by aspirating blood from catheter

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Vascular Access Device Decision Tree


Hemodialysis/Apheresis Catheters

Hemodialysis

Hemodialysis is a method for removing waste products such

as potassium and urea as well as free water from the blood

when kidney function is inadequate (e.g., renal failure).



Apheresis

Apheresis is the process of temporarily removing blood from the

body and separating it into its components.

• Blood is made up red and white blood cells, platelets, and plasma

• Some diseases are caused by excessive numbers of these cells and

by abnormalities of the proteins and other substances dissolved in the

plasma

• During the apheresis process the unwanted component(s) can be

discarded before returning the other components to the body

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• Hemodialysis/apheresis catheters are often large-bore, dual

lumen tunneled catheters.

• Short term catheters are often made of polyurethane, and long

term catheters of silicone.

• Apheresis may also be accomplished via large bore short

peripheral catheters.



• Hemodialysis/apheresis catheters must be clearly marked with

tape, or a printed label:

“Hemodialysis (or Apheresis) Catheter –

Do Not Access Without Permission”




• The facility nurse’s role in the care of the catheter is:

− Ensuring clamps are closed, if present

− Monitoring the integrity of the patient’s dressing and needleless connectors. Dressings are routinely changed during the patient’s dialysis treatments. If the dressing becomes wet, loose, or soiled, and the dialysis nurse is not available, the licensed nurse may change the dressing. A sterile dressing change must be done as soon as possible. Follow dialysis center’s instructions for emergency care and maintenance.

− Notifying the patient’s hemodialysis nurse/nephrologist/LIP if complications occur

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• Because of the large diameter necessary to accommodate the flow rates for hemodialysis and apheresis, flushing/locking protocols are different from other central vascular access devices.

− Hemodialysis/apheresis catheters are usually locked with higher heparin concentrations to avoid the development of intraluminal thrombosis.

− The volume used is usually equal to the internal volume of each specific lumen.

− This high concentration of heparin is withdrawn prior to flushing with next use to prevent heparin bolus.

− Specific orders must be obtained if the nephrologist/dialysis center wants the catheter flushed/locked and/or dressing changed in the post-acute care setting.



Assessment

• Any bleeding or drainage at catheter site must be reported to the

nephrologist, hematologist, oncologist or dialysis center immediately

• In the event of catheter fracture or breakage:

− Immediately clamp the catheter as close to the chest wall as possible

− Position patient in bed on left side in Trendelenburg (head down)

− Notify appropriate physician/LIP

− Arrange for immediate transport to acute care facility for catheter

assessment/repair

A smooth edged clamp must remain with the patient at all times

Next Step

• Complete Exam

• Print/Save Certificate of Completion

• Schedule practicum with your employer

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1/22/2016 - mmlearn.org · 1/22/2016 1 disclaimer •omnicare, inc., as a provider of infusion...

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