Tunneled Catheters

- Long-term catheter (months to years)

- Inserted into vein -> surgically created subcutaneous tunnel
- Insertion site + exit site (exits skin on chest wall several cm from insertion site)
- Dacron cuff – on tunneled portion of the catheter to help anchoring and prevents infection
- Open or closed (single, double, triple lumen)
- Sutures placed at catheter exit site
- Inserted surgically under aseptic technique

- Patient self-care - Regular flushing

- Long dwell time - Body image impact
- Removal by physician

Implanted Venous Access Device (IVAD) – “Dome” or “Port”

- Port surgically and place under the subcutaneous tissue of the chest, catheter attached to the
port and tunneled up to the insertion site (subclavian or jugular vein) threaded into the SCV
- Long term: months to years
- Open and closed (single or dual chamber)
- Access with non-coring needle (Huber point)

- No dressing needed when not in use - Needle access required

- Low risk of infection - Surgical insertion and removal
- Lower maintenance: monthly flushing
when not in use
- Better body image

Complications During Insertion

Irregular Pulse – tip of S+S

catheter is placed within the
- irregular pulse (resolves when catheter is repositioned)
right atrium; leads to cardiac
muscle irritability Management

- after x-ray tip confirmation, professionals can pull catheter

back to the lower (distal) SVC at the cavo atrial junction
- Monitor cardiac rhythm

Prevention

- check tip placement with x-ray prior to use

Arterial Puncture – entry into
an artery (most common in
subclavian insertion)
Pneumothorax – puncture of
pleural cavity
Hemothorax – trauma to a
blood vessel of the chest
S+S
- bright red return
- rapidly expanding hematoma
- respiratory distress
- hypotension
- decrease LOC
Management
- apply pressure to site until bleeding stops
- apply O2
- start large bore IV
- check vital signs including pulse below the site
- prepare for resuscitative measures
Prevention
- inserter to use ultrasound to landmark vein
S+S
- dyspnea
- cyanosis
- shock
- decreased SpO2
- sharp pain in chest & shoulder
- coughing
- diminished breath sounds
Management
- position patient in Fowler’s
- Apply O2
- Call physician STAT
- Assess vital signs
- Observe for unequal chest movement
- Assess bilateral breath sounds
- Obtain chest x-ray post insertion
- Assist with insertion of chest tube
Prevention
- Observe for early signs of pneumothorax
- Obtain post insertion chest x-ray confirming tip placement
and ruling out pneumothorax
- Use ultrasound
S+S
causing bleeding into the - Chest pain
pleural space - Decrease breath sounds
- Dyspnea
- Cyanosis
- Shock

Management

- Position patient in semi-Fowler’s

- Apply O2
- Call physician STAT
- Assess vital signs
- Observe for unequal chest movement
- Assess bilateral breath sounds
- Obtain chest x-ray post insertion
- Assist with insertion of chest tube

Prevention

- Observe for early signs of hemothorax

- Obtain post insertion chest x-ray confirming tip placement
and ruling out hemothorax
- Use ultrasound

Hydrothorax – IV solutions S+S

infiltrate into the pleural
- Chest pain
space
- Dyspnea begins as IV infusion is initiated
- Decreased breath sounds

Management

- Position patient in semi-Fowler’s

- Apply O2
- Call physician STAT
- Assess vital signs
- Observe for unequal chest movement
- Assess bilateral breath sounds
- Obtain chest x-ray post insertion
- Assist with insertion of chest tube

Prevention

- Observe for early signs of hemothorax

- Obtain post insertion chest x-ray confirming tip placement
- Use ultrasound

Injury to Brachial Nerve S+S

Plexus – damage to nerves
 - Tingling fingers
- Shooting pain to involved arm
- Weakness or paralysis of arm

Management

- Assess arm for any S+S of neurological deficits

- Notify physician
- Removes line if still in situ
- Assess arm post removal for neurological damage

Prevention

- Use ultrasound-guided insertion

- Immediate assessment of arm for early detection of
neurological complications

Cardiac Perforation – tip of S+S

catheter (guidewire)
- Sudden/acute heart failure
perforates the heart
- Increased HR, decreased BP
- Muffled heart sounds
- Loss of consciousness

Management

- Activate resuscitative measures

- Continue to monitor patient
- When possible monitor cardiac rhythm
- Notify physician STAT

Prevention

- Inserter should take pre-insertion catheter measurement

- Obtain post insertion chest x-ray confirming tip placement
- Do not rewire catheter

Central Venous Peroration – S+S

puncture of a large vessel that
- Dyspnea
can lead to cardiac tamponade
- Tachycardia
or perforation of the heart.
- Hypotension
Mostly associated with
- Changes in LOC
subclavian vein insertion
Management

- Assess patient post insertion i

- Apply O2
- Notify physician STAT if not at bedside
- Initial CPR
 - Ensure catheter is parallel to the vein wall

Prevention

- Obtain post insertion chest x-ray confirming tip placement

Complications Post Insertion

Air-Embolism – air is down up S+S

through the catheter into the
- Restlessness, apprehension
patient’s vascular system
- Chest pain
through a dislodged, cracked
- Change in LOC
or disconnected CVC or IV
- Cyanosis, pallor syncope
tubing
- Dyspnea
- Tachycardia
- Cardiac arrest

Management

- Clamp the open port and apply occlusive dressing to a

dislodged, cracked or disconnected lumen
- Position patient on left side (this permits air bubble to rise to
upper part of the right atrium)
- Obtain help and call a code
- Administer O2

Prevention

- Ensure catheter connections are secure

- Clamp catheter lumen extension set when changing
administration IV set/cap
- Provide patient education re: catheter displacement and
disconnection
- Educate patient in Valsalva maneuver prior to insertion and
removal
- During insertion ensure that blood is aspirated from each
lumen and then flushed

Phlebitis – inflammation of S+S

the vein (mostly seen in PICC)
- Pain
- Erythema
- Warmth
- Streak formation
- Swelling
- Venous cord
 Management

- Apply moist heat to PICC arm continuously while the patient

is awake during a 24-48 hr period
- Reassess routinely q 4 hr for 20 minutes (for PICCs) post
insertion
- Elevate extremity
- Notify physician
- Follow the phlebitis rating scale
- Contact physician for NSAIDS if appropriate

Prevention

- Apply moist heat for 48 hours q 4 hrs for 20 minutes post

insertion if necessary
- Apply continuous moist heart if phlebitis present or occurs
post insertion
- Call CVC clinical/ IV team / infusion program for initial
troubleshooting

Infection – could be local or S+S

systemic
1) Local
- Purulent drainage, erythema
- Swelling
- Tenderness at site
2) Systemic
- Fever/chills
- Increased WBC
- Malaise
- Hypotension and shock (severe infection)

Management

1) Local
- Contact physician
- Swab for C&S prior to starting antibiotics
2) Systemic
- Contact physician
- Catheter removal maybe necessary if treatment is
unsuccessful
- Obtain peripheral and central blood cultures

Prevention

- Assess site every shift and PRN

- Aseptic technique to be always used during care and
maintenance
 - Monitor vital signs and temperature
- Monitor lab results
- Assess daily clinical need for line

Total Occlusion – inability to S+S

withdraw blood or infuse
- Unable to flush or aspirate

Management

- Do not force flush

- Assess catheter and tubing for kinks in line or tight sutures
- Notify CVC clinician/IV team/ Infusion program/ physician
for thrombolytic therapy
- Report and document occlusion, interventions and response

Prevention

- Routine turbulent flushing (i.e. after meds and blood

transfusions) between meds, and after blood infusions
- Check for lumen patency when flushing

Partial Occlusion – able to S+S

infuse, but unable to
- Sluggish flow of IV fluids
withdraw blood
- Difficulty flushing
- Inability to aspirate blood

Management

- Have patient take deep breath, turn head and cough or do

Valsalva maneuver
- Flush with normal saline
- Change Positive Pressure Cap (PPC)
- Call CVC clinician/IV team/Infusion Program and physician

Prevention

- As per total occlusion prevention

- Do not leave partial occlusion unresolved as it will turn into
total occlusion

Venous Thrombosis – a clot S+S

between the catheter and the
- Edema/cyanosis of arm with CVC line
vein
- Pain
- Swelling of neck, face, shoulder, arm or chest
- External jugular vein distention

Management
 - Observe the client q shift and PRN
- Do not remove the line if S+S of occlusive thrombus present
- Notify CVC clinician/IV team/Infusion program

Prevention

- Assess for S+S of venous thrombosis q shift and PRN

- Check each lumen for patency as per protocol

Extravasation – soft tissue S+S

damage due to leaking of
- Pain or burning during or after infusion in area of vascular
infusate from a vein into the
access device
subcutaneous space
- Unable to get blood return upon aspiration

Management

- Stop infusion
- Notify physician
- Do not remove non-coring needle when port is used
- Warm or cold treatment as ordered per medication protocol
- Follow extravasation protocol

Prevention

- Assess CVC site q shift and PRN

- Check each lumen for patency as per protocol
- When administering highly vesicant/irritant drugs, have
antidotes available and follow administration protocol

Device Malfunction – may S+S

occur for a variety of reasons
- Leaking catheter
- Blood backflow in catheter
- Catheter damage

Management

- Check catheter device q shift and PRN for damage (only for
PICC)
- If line breaks, do not remove, clamp the line with non-
toothed forceps and fold sterile 4x4’s around break
- Call CVC clinician/IV Team/Infusion program or Physician
STAT

Prevention

- Compare measurements to original insertion documented

measurements
- Avoid use of scissors/sharp objects around catheter
 - Ensure line is not twisted or kinked before flushing

Catheter Dislodgement – line S+S

is partially or totally dislodged
1) Partial dislodgement
- Swelling in chest wall during infusion
- Leaking at catheter site
- Pain or discomfort with infusion
- External portion of catheter may have increased in length
2) Complete dislodgement
- Hypotension, tachycardia, pallor, altered LOC
- Obvious bleeding from disconnected tubing
- Catheter is out

Management

1) Partial dislodgement
- Stabilize catheter
- Stop IV
- Position patient supine
- Notify CVC clinician/IV Team/ Infusion program/Physician
- Monitor VS
- Obtain chest x-ray
2) Complete dislodgement
a) Asymptomatic
- position patient flat
- apply pressure x 10 min
- Monitor for S+S of air embolism and hemorrhage
- Notify physician
b) Symptomatic
- Position patient on left side
- Initiate resuscitation measures
- Call physician STAT
- Continue to apply pressure until bleeding stops

Prevention

- Ensure sutures and or securement devices are intact

- Record catheter length with dressing changes and PRN, and
compare measurements to original

Clean Technique – is the use of clean gloves, sterile supplies on a clean work area and a “no touch”
technique

Strict Aseptic Technique – is the use of mask, sterile gloves, and sterile supplies on a sterile work area

Assessment - - Dressing intact, labelling

beginning of - Line secured with StatLock, suture or Steri-strips
each shift and - Continued need for central access
PRN - Exit site status
- PPC attached securely
- Measure amount of catheter visible from the exit site daily

Assess for: infection, phlebitis, thrombus, line patency, CVC Dislodgement

Flushing - Never use a syringe smaller than 10 cc for CVC flushing

- Flush via the PPC
- Scrub PPC with alcohol wipe (15 sec) let dry completely (30 sec)
- Aspirate to check lumen patency
- Flush using turbulent technique push/stop method
- Never force flush against resistance
- Each lumen is treated as a separate lumen

SHOC (open-ended CVC) SO (closed-ended CVC)

Saline Saline

Heparin Off (remove syringe)

Off (remove syringe)

Clamp

Tubing Change - All continuous IV tubing and solution without medication are changed every
72 hours
- All IV solutions with medications are changed every 24 hours

**Exceptions

- Intermittent infusion – IV bag and tubing are changed every 24 hours

- Chemotherapy – secondary IV tubing must be discarded after infusion of
chemotherapy
- Blood product- after 4 hours or 4 units, whichever is first
- TPN – no lipids (Travasol) every 72 hours

- lipids (including 3-in-1 TPN) every 24 hours

Cap change - PPC are changed every 7 days or PRN

- PPCS are used for all CVCs
- Lumen is accessed via the PPC Cap
- Flushing through a PPC facilitates a positive pressure flush
- When cleaning PPC or other connections, use alcohol swab only
- Scrub using a friction rub for 15 secs and let alcohol dry completely 30 secs
 - Aspirate to check lumen patency

Dressing - Transparent dressings are changed every 6-7 days or PRN

Change - Dry, gauze dressings are changed every 48-72 hours or PRN
- indicated for skin sensitivities and oozing sites
- First dressing change is required within 24 hours post insertion of CVC
- Chlorhexidine 2% with alcohol 70% is used to cleanse the site
- When changing the dressing, strict aseptic technique is required

Obtaining - Ensure information on patient’s ID band, specimen labels and the

Blood Sample requisitions match
- When using vacutainer through PPC apply clean technique
- when using vacutainer hub-to-hub apply strict aseptic technique
- when a lumen is used for withdrawing blood samples, the remaining lumens
must be temporarily clamped, and infusion stopped
- if unsure of appropriate specimen tube to use or order of draw please refer
to the lab manual
- discard 5-10 ml ensuring that the specimen is not contaminated (use red
tube or syringe for discard)
- when obtaining blood for coagulation tests (i.e. INR, PTT) slush with 9 ml NS
and discard 10 ml blood
- flush all CVC types with 20 ml NS post blood sampling

Removal - physician’s order is required

- if patient is on an anticoagulant infusion, contact physician prior to removal
- consider patient’s coagulation studies prior to removal, call dr if abnormal
- only RN’s trained in CVC removal can remove percutaneous open-ended
CVCs and PICCs (large bore catheter ex. Cordis and non-tunneled
hemodialysis catheter removal is limited to specially trained staff in critical
care area)
- maintain aseptic technique during removal
- for PICC or femoral CVC removal, position patient supine and instruct the
patient to breathe regularly
- for IJ or subclavian CVC removal, place patient in 15 degree Trendelenburg
position and have pt do the Valsalva maneuver if not contraindicated
- avoid wiping catheter on gauze during removal to prevent site
contamination
- cover site with sterile transparent dressing and gauze for 24 hours post
removal
- monitor patient VS q 15 min x 2 and at 60 min after removal (pt remain in
 bed for 60 min post removal of IJ, subclavian or femoral CVCs)

IVAD - IVAD may be used immediately after insertion

Access/Deacces - Accessed using non-coring needle (Huber Point)
s - Flush every 4 weeks when not in use and ever time IVAD is capped

Accessing

- Locate implanted port via palpation

- Aseptic technique, cleanse site with Chlorhexidine 2% and dry
- Check for patency before infusing
- Flush with NS, turbulent

Deaccessing

- Aseptic technique
- Open-ended: flush with NS -> 5 ml heparin 100 units/ml
- Support the port with index finger and thumb, avoid tilting
- Firmly pull the Huber Point needle out of the device
- Double lumen port: each port has to be flushed separately