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2 150507152224 Lva1 App6892
2 150507152224 Lva1 App6892
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Central Venous catheters or access devices can be
categorized into four groups based on their design:
o peripherally inserted central catheters
o temporary (non-tunneled) central venous catheters
o permanent (tunneled) central venous catheters
o implantable ports.
Although tip location of all central lines may be the same,
insertion sites may vary.
It is the responsibility of the Nurse to be knowledgeable
of the CVADs design, purpose, limitations, and
precautions and to educate patients and caregivers so
they can independently manage their catheters whether
in an inpatient, outpatient or homecare setting.
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By definition, and per its’ acronym, A PICC line is a
peripherally inserted central catheter.
It is a long (approx. 50cm or 20 inches) slender flexible tube
that is inserted into a peripheral vein, typically in the upper
arm of adults and children and sometimes the scalp and lower
extremity of pediatric patients.
The PICC is then threaded along the vein into the subclavian
and eventually into the vena cava and central circulation.
The Registered Nurse should understand that a PICC is a
central venous access device (CVAD) which requires the
same care as other central venous catheters to avoid
complications and achieve positive patient outcomes.
In many Hospitals and outpatient settings the PICC line has
become the preferred alternative to central lines due to cost
effectiveness, ease of insertion and significant lower
incidence of major complications.
Specially trained and certified nursing teams have been
effectively placing PICCs at the bedside, thereby decreasing
costs and enhancing patient comfort.
Major complications such as hemothorax, pneumothorax, and
vessel rupture are not typically present with PICC insertion.
In addition risk of infection is greatly reduced due to the mere
placement of the line: upper arm, verses neck or chest for
central line.
PICC lines are commonly used in acute care settings,
homecare settings and skilled nursing facilities for a variety of
therapies.
They are used for short term therapies of only 1 week to long
term therapies up to 1 year.
Some of the various indications are:
o chemotherapy,
o parenteral nutrition
o repeated blood or blood products
o frequent venous sampling in those with poor venous access
o Central venous pressure monitoring in various critical care areas
Midline 2F: 1 ml NS + 10 2 times administration tubing and add- Pre- and post-blood administration: 1-3 ml NS followed by
APVs units/ml heparin every 6 on set volume locking solution or resume infusion.
[mls] hours NA for routine sampling: for short-term studies follow locked
3 F-0.16 2.6F and larger: 2-3 ml device protocol, discard 1.5 ml for short-term studies from
4 F-0.19 NS + 10 units/ml midline dedicated to sampling
5 F-0.22 heparin every 12 hours
Reference: INS Guidelines Table for flushing
Device APV- Locked Device: Medications: Pre- and Post- Blood Product Administration and Sampling
approximate Volume, Administration Withdrawal Volume for Blood Sampling Accuracy
priming volume Frequency
And Solution
PICC APVs 2F: 1 ml NS + 10 2 times administration tubing and add- 2 F Sampling and pre- and post-blood administration: 1 ml
1.9 F.: 0.06 ml units/ ml heparin on set volume to clear the catheter, then flush with 1ml NS followed by locking
3-3.5 F: 0.2-0.5ml every 6 hours solution until clear
4 F: 0.06 ml 2.6 F and larger: 2.6 F and larger sampling and pre- and post-blood
5 F: 0.4-0.8 ml 2-3 ml NS + 10 administration:
6 F: 0.5-0.6 ml units/ml heparin 1-3 ml NS followed by locking solution or resume infusion
every 12 hours Withdrawal volume: 3 times administration tubing and add-on
set volume
Tunneled and NICU Patients: 1- 2 times administration tubing and add- Pre- and post-blood administration: 1 ml for NICU patients
Non-Tunneled 3 ml NS + 10 on set volume and 3 ml for all others of NS followed by locking solution or
APVs: units/ ml heparin resume infusion
2-3 F 0.12-0.15 ml ever 12-24 hours Withdrawal volume for sampling: 3 times administration
4 F 0.3 ml Pediatrics: 2 ml tubing and add-on set volume. Variation in size makes it difficult
5 F 0.5 ml NS + 10 units/ ml to recommend one volume for all patients.
6 F 0.6-0.8 ml heparin every 24
7 F 0.6-0.9 ml hours
9 F 0.6-1.3 ml
Ports APVs If used for more 2 times administration tubing and add- Pre- and post-blood administration: 3-5 ml NS followed by
[mls] than 1 on set volume locking solution or resume infusion.
0.8 mm I.D.: 0.8 medication daily: Withdrawal volume for sampling : 3 times administration
1.0 mm I.D.: 1.1- 3-5 ml NS + 10 tubing and add-on set volume. Variation in size makes it difficult
1.2 units/ml heparin to recommend one volume for all patients.
1.1 mm I.D.: 1.2 Monthly
1.4 mm I.D.: 1.7 maintenance
1.6 mm I.D.: 2 flush: 3-5 ml NS
+ 100 units/ ml
heparin
Reference: INS Guidelines Table for flushing
NACL Dextrose Heparin Heparin, Cont.
GENERIC BRAND GENERIC BRAND GENERIC BRAND GENERIC BRAND
Aldesleukin Proleukin ® Baclofen Lioresal® Alteplase Activase ® Gentamicin Slulfate
Amphotericin B Haldol
Cholesteryl Sulfate Amphotec® Bupivicaine Marcaine® Amikacin Haloperidol Decancate Decanoate®
Amphotericin B
Deoxychoate Fungizone® Cladribine Leustatin® Amobertibal Sodium Amytal® Haloperidol Lactate Haldol®
Amphotericin B Lipid Amphotericin B Cholesteryl
Complex Abelcet® Clonidine Duraclon® Sulfate Amphotec® Hyaluronidase Hydase®
Amphotericin B Amphotericin B Hydrocortisone Sodium
Liposomal AmBiosome® Dantrolene Dantrium® Deoxychoate Fungizone® Phospate Solu-Corte F®
Dantrolene Sodium Dantrium® Daptomycin Cubicin® Atropine Hydroxyizine HCl
Filgrastim Neupogen® Levothyroxine Sodium Synthroid® Clarithromycin Biaxin® Levorphanol Tartrate Levo-Dromoran®
Immune Globulin Bammunex® Methadone HCl Dolophine® Codeine Methylprednisolone Solu-Medrol®
Liposomal Doxorubicin Doxil® Phenytain Dilantin® Cytarabine Tarabine® Mitoxantrene HCl Novantrone®
Methoxamine Vasexyl® Streptomycin Streptomycin Daunorbucin Hcl Cerubidine® Morphine Sulfate
Mycophenolate Mofetil
HCl CellCapt® Tenecteplase TNKase® Diazepam Valium® Nesiritide Natrecor®
Nitroprusside Nitropress® Treprostinil Sodium Remodulin® Dexorubicin HCl Adriamycin® Norepinephrine Bitartrate Levophed®
Reference: Box 23-5 Infiltration Scale. Page 472 Infusion Nurses Book.
Infection: May develop either inside the vessel or at the
insertion site.
o Site should be inspected daily for any redness, pain, swelling,
pus-like drainage or fever and chills and should contact the
nurse or MD immediately if develops.
o Typically the source is directly related to the dressing covering
the site and often due to a dressing becoming wet.
o Once wet, moisture and body heat become an ideal breeding
ground for bacteria.
o Patients/caregivers must be educated to report wet, soiled or
compromised dressings.
Occlusion: A catheter that becomes sluggish and difficult to
flush, or unable to flush could indicate a partial or total
occlusion.
o Intraluminal occlusions occur as a result of blood clot formation
within the catheter, medication incompatibilities or precipitates.
o Extraluminal occlusions result from formation of distal fibrin sheath,
catheter malposition, or mechanical obstruction (kinking).
o Factors that predispose a catheter to occlusion are multiple infusion
therapies, frequent blood sampling and improper flushing.
o The patient/caregiver should be instructed to contact the nurse or
physician for troubleshooting or early intervention.
o Catheter should be assessed appropriately, and managed
accordingly.
o Use of an anti-thrombolytic agent may be indicated to prevent
disruption of therapy and prevent further complications.
• Anti-thrombolytic agents such as Cathflo can be used in midlines and CVADs when
Migration/dislodgement and damage: This occurs most
often due to improper anchoring of device or excessive
pressure when flushing the CVAD.
o Any signs or symptoms of leaking at catheter site, wet dressing,
swelling, burning, or pain in the arm, shoulder or neck should be
reported.
o Patient should be instructed to stop using the catheter and, if
there is a visible crack or leak, apply a clamp above the site
close to the catheters exit site, if possible.
o Catheter repair kits are available but not routinely available for
home use due to the many different manufacturers and types of
CVADs.
o Notify nurse/physician immediately.
Although the home care nurse provides expert clinical
assessment, judgment and care to the CVAD, the patients
and caregivers are ultimately responsible for the day to day
care of the CVAD.
Patient education becomes a critical intervention in safe and
reliable home infusion therapy and CVAD care.
Many factors, physically and mentally, affecting patients or
caregivers ability and readiness to learn must be assessed
and routinely evaluated.
Aseptic technique and hand hygiene should be repeatedly
reinforced, demonstrated and observed.
Patients and caregivers should be taught to inspect the site
and dressing daily for any irregularities and given clear and
simple instructions about what and when report.
1. INS: Infusion Nursing Standards of Practice. Nursing Journal of Infusion 2011; 34, (1S) S37-S68
2. Hadaway, L. INS: Journal of Infusion Nursing: Short Peripheral Intravenous catheters and Infections 2012; 35(4) 230-235.
3. Carlos do Rego Furtado, L. INS: Journal of Infusion Nursing. Maintenance of Peripheral Venous Access and Its Impact on the Development of Phlebitis 2011;34 (6) 382-389
4. Dychter, S, Gold, D, Carson, D, Haller, M. INS: Journal of Infusion Nursing. Intravenous Therapy 2012; 35 (2) 84-91
5. Perucca, R. INS: Infusion Nursing, an Evidence Based Approach: Peripheral Venous Access Devices: Chapter 23 pp 456-479
6. NHIA: Central vascular guidelines for the Adult home based patient 6/25/11
7. INS: Policies and Procedures for Infusion Nursing 3rd edition. 84-102, 124-132
8. Lyons, M, Phalen, A. NHIA Infusion. An Evidentiary Review of Flushing Protocols in Home Care Patients with Peripherally Inserted Central Catheters 2012; 18(5) 32-40
9. Kramer, N Leone, M, Ross, K, Shaps, F, Cain, D. NHIA Infusion. CVAD Guidelines for Home Infusion. 2011; 17 (4)29-36
10. Hadaway, L. Targeting Therapy with CVAD: Nursing: 2008; 38(6) 35-40
11. Hufcut, T. Choosing an Effective and safe Central Venous catheter. An Evidence based Approach. Picclinenursing.com
12. Seigel, M. Kraemer-Cain, J. PICC Line Care at Home. Advance for Nurses. Nursing.advanceweb.com
13. Funaki, B. AJR Review. Central Venous Access: A Primer for the Diagnostic Radiologist. 2002; 179 (2)
14. Gorski, L. Home Healthcare Nurse. Central Venous Access Device Associated Infections: Recommendations for Best Practice in Home Infusion Therapy. 2010; 28(4) 221-229
15. CDC: Healthcare Associated Infections.(HAIs) Basic infection Control and Prevention Plan for Outpatient Oncology Settings
16. Bullock-Corkhill, M. INS: Infusion Nursing, an Evidence Based Approach: Central Venous Access Devices: Access and Insertion Approach, Chapter 24: 480-493
17. http://nursinglink.monster.com/training/articles/302-the-use-and-maintenance-of-implanted-port-vascular-access-devices
www.journalofinfusionnursing.com
18.http://infonet2.upmc.com/OurOrganization/Enterprise/Quality/Infection/Pages/Central-Line-Toolkit.aspx