vascular access via central catheter educational module

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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

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.

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Enabling Objectives

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.

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Enabling Objectives

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.

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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

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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

– 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

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Types of Vascular Access Devices

Non-tunneling Tunneling Implanted

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Non-Tunneling

Direct venipuncture through the skin into a selected vein.– Peripheral VADs– Peripherally inserted central VADs– Percutaneous catheters

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Non-Tunneling-Peripheral VADs

Butterfly & angiocaths– Short catheters generally placed in forearm, hand

or scalp veins– Short term therapy and unable to handle caustic

chemicals (chemotherapy)

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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

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

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Non-Tunneling - PICC

Peripherally inserted central catheters (PICC)

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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

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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)– Subclavian or internal jugular– Single, double or triple lumen

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Non-tunneling - CVC

Tip advanced to superior vena cava and right atrium

As with PICC, appropriate for patients requiring long term chemotherapy or TPN

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Non-tunneling CVC subclavanian site

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Tunneling

Hickman®

Broviac®

Groshong®

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Tunneling

Inserted 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

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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

Catheter attached to a self-sealing silicone septum surrounded by a titanium, stainless steal or plastic port

Port sutured under the skin

Some brand names:– Port-a-cath®

– Infus-a-port®

– Power Port ®

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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

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Can only be accessed with special needle called a HUBER needle

Contains a deflecting, non-coring point

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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.

– Poor skin/ wound preparation of a contaminated wound

– Other routes

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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

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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

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Factors that Contribute to Infection

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

– 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

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

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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 <aseptic techniques>2: free or freed from pathogenic microorganisms <an aseptic operating room>

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Sterile

Free from living organisms and especially microorganisms <a sterile syringe>

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.

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Aseptic Technique

Barriers are established to control the spread of microorganisms by:

– Protecting sterile areas

– Isolating surgical wounds

– Keeping free microbes to a minimum

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Aseptic Technique

Skin– Washing with soap (antimicrobial) before and after patient

contact

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

– Donning gloves

Mouth and nose

– A mask should be worn

– People with respiratory tract infections should not work with open wounds

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Aseptic Technique - continued

Fomites - nonliving material such as bed linen that may transmit microorganisms

– Should be packaged and stored properly

– Clean and soiled supplies should be physically separated

– Prompt decontamination of used equipment and reusable supplies

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Sterile Technique

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

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

infected

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

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

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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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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

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

Items dropped below waist level will be considered unsterile

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Tables are considered sterile at table level only– 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

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Only persons that are sterile touch sterile items

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

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.

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

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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:– Prophylactic IV access– Suspected infection at skill site

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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

10 ml syringe (empty)

10 ml syringe (normal saline)

Sterile gloves (if available

Alcohol preps 250 – 1000 ml

normal saline and administration set

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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

You will not always be able to tell the largest.

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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.

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Clamping end of the cap

Ensure the clamp is properly secured Clamp

End cap

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Prep end of lumen with alcohol swab

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Flushing

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

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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

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Accessing & Administration

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

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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

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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

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

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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.

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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

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-A-Cath® Infus-A-Port®, Mediport®)-Accessing and General Information. October 2005

Cook Medical, Bloomington, IN Ohio State University Medical Center, Sterile Technique, June 2004

vascular access via central catheter educational module

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